Clifton House

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 requires improvement. At this assessment the rating is 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 demonstrated a shared vision and direction to support continuous learning and improvement. For example, the provider maximised opportunities to strengthen service culture and direction, and engage with others by ensuring changes relating to people’s needs and safety events were reported to healthcare professionals and external partners.

The provider worked closely with people, relatives and staff to create an inclusive culture. There were complaints and equality and diversity policies in place. Staff received training in both these areas and told us they were able to speak to leaders should they have concerns.

Staff meetings and people meetings were held by the leaders which reinforced the values and expectations of the service. Leaders also used satisfaction surveys to obtain the views of staff.

People and relatives told us staff regularly consulted with them about the care their relatives received; their views were obtained via their relative’s care plan reviews and satisfaction surveys, and they felt able to raise concerns and were confident leaders would take appropriate action.

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.

With exception of the application of the Mental Capacity Act 2005 (MCA) not being fully applied in one case, which the provider quickly addressed, the provider demonstrated effective leadership. For example, safety events were appropriately managed, people were safeguarded, care records contained clear and detailed information about people’s needs and preferences and people’s and relatives’ views were sought. The principles of ‘Right support, right care and right culture’ guidance were applied to how people were supported and their care records, and staff were suitably recruited, inducted, trained and supported by leaders.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Effective systems and processes were in place to ensure safety events were always analysed and, where required, reported, people were safeguarded and care records contained adequate guidance for staff. Systems were effective in ensuring people received person-centred care and that their needs and preferences were understood and met by staff.

Effective systems and processes were not in place to ensure the application of the Mental Capacity Act 2005 (MCA) in one case. However, we saw adequate regard for the MCA in other areas.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 had made improvements to the areas highlighted within the service’s previous inspection report, for example, in relation to safeguarding people from harm and abuse.

The provider had a clear awareness and understanding of audit processes and how these could be used to effectively identify concerns and mitigate risks to achieve continuous learning and improvement. For example, where people were exposed to risks of harm and injury, the provider ensured events were managed in a way which supported understanding and learning to mitigate future risks.