Penrose Court

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated this key question requires improvement. At this inspection the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider and registered manager had a shared vision, strategy and culture. The culture at the service was positive. People were happy and relaxed being supported by the staff team. Relatives gave us mostly positive feedback about the service. Staff enjoyed working at the service. The registered manager and wider management team promoted staff to do what was best for people. They were aware of some aspects of people’s support which may need improvement and were already taking action in these areas. Staff completely understood the importance of respecting people’s home as theirs and ensuring they supported people as best as they could. The providers values were understood by the management team and discussed regularly with staff. People’s comments included, ‘‘This is how a care home should be run. Staff have a lot of care and empathy.’’ And ‘‘If you are looking for a friendly, clean, homely place with plenty to do then this is it.’’ A relative said, ‘‘Everything is perfect. The room is great, [family member] loves the food and activities and the staff are excellent.’’

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Staff told us the registered manager and management team were approachable and included them in discussions about the service and how best to support people. The registered manager and management team were capable in their roles and had a good oversight of the service. They understood their regulatory responsibilities and took action to improve where necessary. The registered manager and deputy manager were a part of the staff team and were very visible at the service making sure they spent time with people and the staff team. They knew people well and were able to step in and support the staff team if this was needed. One staff member said, ‘‘[Registered manager] is one of us and leads by example. We never do anything they would not be comfortable doing themselves.’’ The registered managers office was always open, and people and the staff team were able to enter and speak with them when they chose to. A person said, ‘‘[Registered manager] has their finger on all the buttons. We always see them, and they check on us all the time.’’ A relative told us, ‘‘“It is a well-run home with really great caring staff. All of them chat and are really friendly. I have no concerns about the care.’’

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was a complaint and speaking up policy in place at the service. Where people and relatives had raised concerns in the past these had been looked in to and addressed promptly. Staff told us they knew how to raise concerns and felt comfortable and confident in speaking up at the service. Information about how to raise concerns was available for people in different formats. People, relatives and the staff team were invited to feed back and share ideas regularly including reviews and discussions about people’s care plans and risk assessments. One person told us, ‘‘Any little niggles I have I just let staff or [registered manager] know and this is all sorted out quickly.’’ A relative said, ‘‘We are happy with everything but know how to raise things if we should ever need to. We talk about [family member’s] care plan regularly.’’

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they enjoyed working at the service and felt well supported by the management team. The provider supported their equality and wellbeing by offering preferred working patterns and discussing their job roles with them regularly. The providers recruitment process was fair and equitable.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. Whilst audits were being completed at the service, these were not always effective in identifying areas where improvements could be made. For example, in areas such as some care plans being more detailed, making sure people were consistently supported to have engagement and follow their interests and some aspects of environmental safety. Some areas of environmental safety had been raised to the provider but had not been actioned, although this was rectified during this inspection. The registered manager was aware of these areas and was also receptive to our feedback. They told us the plans they had to improve the service.

However, other audits and governance measures at the service were effective. The registered manager and management team had a very good oversight of areas such as the monitoring of people’s health care needs, medicines and the reviewing of policies and care plans. There was a continuity plan in place to effectively deal with an emergency situation at the service. A person said, ‘‘You could not ask for better management. They are on top of everything.’’ A relative told us, ‘‘I cannot fault them. Our experience so far could not have been better.’’

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The management and staff team had good working relationships with partners such as health professionals and local authorities. They worked in partnership with them to help make sure people had the best care possible. Staff were encouraged to organise opportunities for people to be a part of the local community. People had been supported to access areas such as cafes and restaurants, local parks and places of worship. These were very much enjoyed by people and the staff team were in the process of speaking with people to identify further opportunities for them. A person said, ‘‘[Staff] always ask me if I want to go out and about. I change my mind all the time but they know I enjoy it so they try and encourage me to go if I can.’’ A relative said, ‘‘I am pleased there are still opportunities for [family member] to go out. This is important to them.’’

The provider focused on continuous learning, innovation and improvement. The management team had improvement plans in place based on findings from internal and external audits and findings. The registered manager had produced a detailed service improvement plan and actions from this were monitored by them and the provider. Staff supervisions and team meetings focused on and discussed where people’s support could be improved. The registered manager was receptive to our feedback and was already aware of most of the areas we identified as needing improvement at this inspection. They had started to take action in these areas. The service had improved since our last inspection. One person said, ‘‘The home is in a good place now and it keeps getting better.’’ A relative told us, ‘‘[Staff] are always looking to tweak things and make them a little bit better and [registered manager] is very receptive to any feedback. They really want to make a difference.’’