Graysford Hall

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 good. At this assessment the rating has remained 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 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.

Our observations and feedback from people, relatives, and staff showed the service had a positive, open, and welcoming culture which centred on the well-being of the people living there. A staff member told us, “I would put my relative here. I see how the staff care for people, staff treat everyone as an individual, they adapt to each resident.”

Relatives said the service had an inclusive culture and staff kept them informed about their family members’ progress. A relative told us, “They let us know about everything as we live away, they even sent a video of [person’s] room and lots of information, which was so helpful.” Other comments from relatives included: ‘they talk to us often and give us updates’; ‘we get a weekly newsletter, which has all the planned activities, which is nice to know’; and ‘I am fully informed of any changes or issues’.

The culture and values of their workforce and organisation had been negatively affected at times by the lack of a permanent manager.

At the time of our inspection the service did not have a registered manager. People and relatives told us there had been several different managers at the service and they found this unsettling. A relative said, “[Family member] has been here 20 months and there have been 5 managers and that doesn’t help.” Staff said the service needed a permanent manager for stability.

A new manager had been appointed and had applied to CQC for their registered manager status. People told us they had already had a positive impact on the service. A person said, “The new manager will be very good, I’ve got a great feeling about them, the home feels different since they arrived.” A relative told us, “Our issue has been the lack of a manager and the chopping and changing that brings but hopefully this new manager will settle things down.”

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

Staff were confident about speaking up if they had any concerns about the service. A staff member said, “Managers are always available, including higher managers who visit quite often. We can speak to them.”

Staff attended monthly meetings with managers when they had the opportunity to share their views on the service. Staff could also raise issues at daily handovers and ‘flash’ meetings. A staff member said, “It works OK, we [staff] get listened to.”

The manager had an open-door policy and said people, relatives, and staff were always welcome to call in if they had a concern, a compliment or just wanted to say ‘hello’. People, relatives and staff said the manager was approachable and they felt they could talk to them at any time. If anyone wanted to go direct to the provider, their number was available at the service.

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 Graysford Hall was established, multicultural and diverse. The recruitment process included competency-based interviews to help ensure equality and inclusion. Staff were supported to follow the principles of their religious and/or cultural beliefs. The staff rota was flexible to enable staff to have a manageable work/life balance.

Staff felt valued and respected. They said they felt part of a team with the shared goal of providing people using the service with high-quality care and support. They told us managers listened to them and acted on what they said. A staff member commented, “We get good support from management and always get a rapid response to shortfalls, e.g. lift breakdown, and we always have the equipment needed. We are well-resourced.”

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 provider, regional manager, and manager completed regular audits of all aspects of the service to ensure it was running safely and effectively. The regional manager carried out a compliance visit once a month and supervised the manager. The service had a ‘home development plan’ that staff and managers followed to enable continuous improvement.

Accidents and incidents (including safeguarding incidents) were logged and analysed. This meant managers had an overview of untoward events at the service, could identify any trends, and ensure lessons were learnt where necessary.

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.

Staff and mangers worked in partnership with key organisations to support care provision, service development, and joined-up care. The service was developing relationships with a range of multidisciplinary teams and individuals including health and social care professionals and local authority commissioners. For example, the service monitored falls, and records showed they collaborated with the local authority falls team and GPs to reduce the risk of these happening.

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.

Staff and managers ensured that people and relatives were involved in changes and improvements to the service. For example, a few people were dissatisfied with the menus, so the head chef attended a residents’ meetings to listen to people’s views. People also completed a survey about their dietary preferences. Changes were made to the menu and people and relatives told us they were more satisfied with the food served.

There were processes to ensure learning happened when things went wrong. Investigations were carried out and learning cascaded to staff to reduce the risk of accidents/incidents. Managers encouraged staff to reflect on accidents/incidents to see what they could have done differently to keep people safe.