Archived: Clitheroe Care Home

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 assessment we rated this key question inadequate. At this assessment 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 75 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider shared information about the culture of the home with new staff as part of their induction, and details of the home’s values could be found on their website. Observations during our inspection evidenced staff had a clear understanding of the provider’s values and prioritised safe, high-quality, compassionate care.

The provider ensured the culture of the service was empowering, inclusive and developed through collaboration with others. Records evidenced a clear focus on seeking regular feedback from people, relatives, staff and partners, and learning from this.

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.

The provider ensured good quality leadership was sustained through safe, effective and inclusive recruitment and succession planning. The registered manager had been recruited safely and had previous experience within the care sector. They were provided with ongoing support from senior managers, and shared learning with the provider’s other homes; to continuously improve their knowledge and skills.

Staff confirmed the registered manager led by example and modelled inclusive behaviours. A staff member said, “[Registered manager] doesn’t always stay in the office. They do lots of walk arounds and seem to know the job well.” Another added, “[Registered manager] is a good manager, approachable and supportive.” Throughout inspection, the registered manager demonstrated a good understanding of people, the service, it’s key issues and priorities.

The registered manager and deputy manager were alert to signs of poor culture and took action to prevent this. For example, by reviewing interactions and staff conduct regularly as part of staff supervisions, observational competency checks and monthly audits.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider encouraged staff to raise concerns via staff supervisions, regular meetings and surveys. The latest staff survey confirmed managers were approachable and staff felt listened to. An analysis of results was completed by senior managers and, ‘you said, we did’ information was shared, evidencing actions taken in response to feedback.

Staff received training in raising concerns and whistleblowing, and confirmed they were able to voice concerns without fear of detriment. A staff member said, “Yes, of course (I feel able to speak up). [Registered manager] would ask me to come to them with any issues and things are discussed at team meetings.”

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.

The staff team at the home was diverse, and those we spoke to confirmed they felt valued and were fairly treated. Several staff members were employed from overseas. The appropriate checks were in place, and any conditions of sponsorship were being met by the provider. A staff member said, “Everyone is treated the same. Some [staff] have conditions about their hours and [the provider] always makes sure we are meeting those.”

The provider took action to prevent and address bullying and harassment. Staff had access to an employee handbook which included information around discrimination, harassment and how to complain. Several staff commented positively on their treatment from the registered manager and colleagues. A staff member said, “It’s a nice team to work in, people share tasks and help each other.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The registered manager and deputy manager conducted daily, weekly and monthly checks to ensure they had good oversight of the home. Digital systems were used to audit health and safety, IPC, medicines and care interactions, and alerted the registered manager to any upcoming or missed tasks.

The provider had robust arrangements for the availability and integrity of data and records, and information was used effectively to monitor and improve the safety and quality of care. Senior managers conducted monthly visits to check the home’s compliance with recognised standards and good practice, and a remote team monitored data to ensure information was correct and contemporaneous. Findings were fed back to the registered manager, and action plans put in place in response to any concerns.

The provider’s business continuity plan detailed their preparedness for emergencies and adverse events.

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 registered manager and staff worked in partnership with a range of local services and healthcare partners to share learning, promoting continuous improvement and better outcomes for people. For example, the district nursing team, medicines optimisation team, care home team and local GP practice. The registered manager explained their involvement in registered manager networks and attended a local authority forum.

The home was embedded within the local community; hosting church services or visits from local schools and organising an open day for people, relatives and members of public to enjoy.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider supported continuous learning and improvement. Monthly management meetings focused on the standards of people’s care, their experience and quality of life. The registered manager gave examples of ongoing improvements, telling us, “Safety had improved a lot (since the last inspection). There’s a good learning culture and enough investment. We are currently trying to upgrade the home.” People and relatives commented positively on the improvements made to the management of the home.

The provider had worked collaboratively with the local authority’s quality monitoring team, to improve the service since our last inspection. The report from their most recent visit showed requirements had been met, with evidence action had been taken in response to the 2 recommendations made.

The provider, registered manager and senior managers genuinely welcomed feedback, even if it was critical, and could demonstrate what actions had been taken in response. They engaged positively with our inspection, responding to queries and promptly acting on concerns raised. For example, to environmental issues and documentation.