Combe Lea 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 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.

Leaders held a ‘Values Day’ and staff attended a 'Values' session during the day as part of 'Values week' and were invited to feedback to the organisation. While staff responses were mixed, leaders felt the evening encouraged openness and created a culture where staff feel safe to speak up and challenge when needed One staff member said, “we are a well-established team, and we all work well together.” Leaders said service objectives and values were introduced to staff during their induction and reinforced through regular supervision, ensuring they are put into practice every day. This meant staff understood the service goals and values and applied them consistently in their work, helping to maintain high standards and a positive culture throughout the service.

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 service had a stable and experienced management team. The registered manager and deputy managers had worked at the service for a number of years. Both staff and relatives spoke positively about the leadership, describing the team as approachable and supportive. Staff told us they felt well supported in their roles. Opportunities were created to encourage staff to develop their skills and learn. One leader said they look at progression and succession with staff and have encouraged staff to apply for senior team roles. They said, “It is about looking at the skills in the person, spotting leadership qualities and building future leaders. One senior leader said, “I enjoy putting managers in a place where they can be stretched, learn and are given opportunities to develop their management skills.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Systems were in place to encourage staff to speak up. A whistleblowing policy was in place and actively promoted so staff know how to raise concerns.

Leaders introduced initiatives such as ‘feedback Thursday’, where staff could talk to managers about anything they wished. Staff told us they felt confident to speak up if they had any concerns. Records of team meetings showed staff were regularly given opportunities to feedback. Leaders told us about changes they had made as a result of listening to staff feedback, for example, changing staff working hours to improve staff work life balance.

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.

There were policies to uphold equality and diversity and staff who needed workplace adjustments were supported. Leaders also made provisions to respect staff’s religious needs. For example, a dedicated prayer space was provided, and breaks were arranged to allow staff time to pray.

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 had good oversight of the home and carried out regular audits. The outcomes of these audits were shared with the leadership team to help maintain high standards.

The registered manager understood legal responsibilities to notify the Care Quality Commission (CQC) about certain changes, events and incidents that affected the service. These notifications were submitted correctly.

We noted the service action plan did not always record the steps taken to resolve outstanding issues, for example, explaining delays in updating the service user guide. Leaders told us they would improve this process to ensure all actions and explanations were documented in the future to help make the action plan more transparent and effective.

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.

Leaders told us the service had built strong links with local organisations, which have been mutually beneficial for people and the community. For example, students from a local college visit to offer health and beauty treatments, and children from a nearby school come in to do activities, for example reading or planting up pots with people. People told us that the local church and vicar visit the service regularly to offer support and hold services for those who wish to take part.

Health partners provided positive feedback about the service. One health care partner said, “I feel the care in Combe Lea to be exceptional, and this would be the only residential home in the area that I would be happy for members of my family to live in”

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. Leaders told us how they shared information across services through staff briefings and newsletters to embed learning. For example, learning from incidents and quality assurance audits. This meant important information and lessons were shared consistently across the service, helping staff learn from incidents, improve practice, and maintain high standards of care.

Staff were recognised and celebrated for their good work through a staff accreditation scheme.

Leaders told us the service had been involved in a pilot scheme aimed at supporting people on the dementia pathway to receive a diagnosis. They explained that having a formal diagnosis has made a positive difference for residents, helping plan their care more effectively and ensuring they receive the right support.