Cleeve Court Community Resource Centre

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 has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 62 (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 management team had a shared vision, strategy and culture. They engaged people and staff in making decisions. Leaders promoted diversity and human rights for people and staff by seeing everyone as individuals.

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 or were willing to learn them. They did so with integrity, openness and honesty.

Throughout the inspection the management team demonstrated openness, honesty and integrity. The deputy managers ran each floor and were overseen by the registered manager and the provider’s representatives. All people, relatives and staff were complimentary about the management team. They had open doors for staff to speak with them at any time.

The management placed people at the centre of their work and wanted to always ensure people were safe and received quality care. Work was being done with other services within the provider’s services to gain knowledge and experience where there were shortfalls in their knowledge.

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

Staff felt they could raise their concerns and action would be taken. Although on occasions there were cases where speaking up had not been passed up the management line even if resolved. We raised this so they could learn from this and modify their systems. The provider’s representative told us they would take this on board.

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.

Systems were in place to ensure all staff were treated fairly and there was a focus on equity. They had systems to ensure staff had an induction and listened when they could do things better. All staff received supervisions and there were regular team meetings. When managers had made an error they were quick to apologise and accept responsibility.

The provider still did not always have clear responsibilities, roles, systems of accountability or good governance. They did not act in a timely way on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had established external and internal systems to audit the safety and quality of the care people received. However, when actions were identified as being required these were not always managed in a timely manner. For example, work on the garden to allow safe access for people had been delayed by the provider’s own systems. Work was now planned to be completed following the inspection.

An external provider completed an audit on the service and provided a report in May 2025. Actions were still outstanding such as improvement of the care plans and improved application around capacity and consent. We shared our concerns with the provider’s representative who immediately took actions to make improvements. They updated an action plan with us throughout the assessment process and changes were witnessed. It was too early to determine if these changes were sustainable.

The management were aware of all the concerns we raised during the inspection. There were plans in place to resolve many of the issues and those that were not resolved had delays beyond their control.

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.

Systems were in place to work with other health and social care professionals. During the inspection a visit from the GP occurred and there were regular visits from the district nurses. The service also reached out to other specialist services run by the provider to gain knowledge on areas they were less confident. For example, seeking training for staff on supporting people with learning disabilities and autism.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. Although this was not always acted on in a timely way. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They did not always act in a timely manner when contributing to safe, effective practice and research.

Systems were in place for the management to learn and continuously improve the service. However, when proactive actions such as internal and external audits had been completed these had not always led to change in a timely way. Some of the barriers included the home moving between a different provider when the local authority had subcontracted out the service. Other factors included having to break down the local authority systems. In turn, this had slowed down the changes and learning at times out of the managements control.