1 Fengates Road

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 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 clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an understanding of the challenges and the needs of people and their communities.

The management team told us they ensured the staff were valued and promoted people’s individuality, protected their rights and enabled them to thrive. Staff told us there was a good and positive culture within the home where people and staff had a good rapport, and the atmosphere was one of respect and care.

The provider set a culture that valued reflection, learning and improvement. The registered manager effectively used staff supervision and regular team meetings as a platform for staff to raise any concerns and an opportunity to share their views and opinions.

The management team were passionate and committed to developing the service for the benefit of people who used it. The regional manager told us, “We are planning to do the garden. This is high on the agenda. We want it done by the summer. Then hoping to have a garden party.”

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.

People knew who the registered manager was and told us they had a good relationship with them and the rest of the staff. One person told us, “The manager and deputy are really really good. I have been here a long time, and I am not going anywhere else.” A relative echoed this and said, “The manager is responsive. I also have a good rapport with the deputy manager. They both have a good understanding of my relative’s needs.”

All the staff we spoke with were positive about the registered manager and provider. They told us the service was good and the managers valued and respected them. They added the managers put people at the centre of everything they did and led a staff team by example. A member of staff told us, “I have huge respect for [registered manager]. [They] work so hard, doing more hours than they should. I feel that we need to support [them] and take some of the pressure off.”

The registered manager had worked their way up from support worker and had developed a good knowledge of the client group they supported. They told us they enjoyed working at the service and had a good relationship with staff and people alike.

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

People and relatives were given information when they moved to the home about how to raise a concern and said they knew how to make a complaint.

People were supported to share their feedback about the service via regular meetings and surveys. We saw evidence their comments were taken seriously, and appropriate actions was taken as a result. For example, one person said they would like a new bed. The registered manager told us they were in the process of supporting the person to choose one. Another person had complained they would prefer smaller food portions and food of a softer consistency. This message was relayed to staff to ensure they met the person’s needs when preparing their meals.

The provider had some processes in place to support staff to speak up. This included supervision meetings, handover meetings, staff meetings and a whistleblowing policy. Staff had also received training in safeguarding to reinforce their understanding and their responsibility to speak up.

In addition to regular staff meetings, there were daily handover meetings to discuss important information, and any risks to service delivery. There were processes to support managers and senior staff in meeting their responsibilities.

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 provider had policies to promote equality, diversity and inclusion and to protect staff from discrimination and harassment. Staff were supported to develop their skills within the company. The registered manager told us, “Generally we have good staff retention. We are looking at promoting some staff to senior staff. Interviews will be happening soon.”

Staff’s needs were reviewed and reasonable adjustments made as necessary, for example if they had health related issues. The registered manager told us, “Rotas have been adapted to accommodate these requirements while ensuring the needs of the people we support remain fully met.”

Where staff experienced childcare difficulties, the provider supported them to submit a flexible working request. The registered manager told us, “Where possible, I authorise rota changes. If adjustments cannot be accommodated within the home, I contact other home managers in the locality to explore alternative support or shift availability.”

Staff’s cultural and religious needs were supported. The registered manager told us whilst the needs of the people they supported remained the priority, they asked the staff to inform them of upcoming celebrations or observances prior to the rotas being finalised. They said, “I typically ensure they can take at least one of the key religious holidays over Christmas/New Year and apply the same approach at Easter. Some staff choose to attend church on Sundays, and I adjust rotas where possible to facilitate this.”

Where staff required support with prayer and fasting requirements, the registered manager told us, “Staff inform me of their needs in advance, and I encourage them to align prayer times with their rest breaks. We provide privacy for prayer, either in the office or the vacant bedroom.”

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.

Staff at all levels understood their roles and their level of accountability. Managers and support staff worked well together and understood how their duties impacted and supported the other.

Staff, people, relatives and external professionals had confidence in the leadership of the service. A staff member told us, “The manager is always supportive. Everyone is lovely here. I feel supported. We work together well” and another said, “The manager is very approachable and supportive.”

There were systems in place for monitoring the quality of the service and these were effective. Action was taken when audits identified the need for improvement.

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 told us they worked well with healthcare professionals to ensure people’s needs were met. The registered manager confirmed they had a good working relationship with a range of external professionals. For example, the GP, the local authority and commissioning managers.

The provider had systems and processes to ensure people’s needs were reviewed with external professionals. The provider listened to feedback from them and where a need was identified, amended their policies and procedures to promote effective communication and partnership working.

The registered manager told us they ensured the staff learned from healthcare professionals involved in people’s care to help understand people’s needs better. Our conversations with various support staff showed they understood people’s needs and were keen to learn from professional input.

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.

People told us they were consulted individually during a review or regular conversation, to find out if they had any concerns or requests. We saw people’s opinions and requests were taken seriously.

Staff told us the registered manager was always aiming to make improvements to the service in order to benefit people, and they enjoyed being part of this.

The registered manager was committed to developing the service to benefit people and the staff team. They had introduced a monthly newsletter which kept everyone informed of news and development within the service.