Churchill 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.

This is the first assessment for this service. This key question has been rated 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.

The service was in breach of legal regulation in relation to good governance.

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 provider had values that confirmed what people could expect of the service and staff. This included valuing everyone, making things happen, having fun and being brave. Staff meetings were an opportunity for the manager to review any changes to people’s care and support, and for staff to raise any information the manager needed to know. All staff felt supported by the manager of the service and able to raise any concerns should they need to.

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 manager and deputy knew people well and they were accessible within the service should people or staff need to raise anything with them. Staff told us, “It’s great working here” and “It’s a good team”.

The provider and managements within the service had a positive culture where people felt they could speak up and their voice would be heard. Staff had regular staff meetings, supervision and debriefs following any incidents and accidents. Staff views were sought through provider staff surveys and the manager and deputy were available should staff wish to raise anything with them. All staff felt able to raise any concerns with the manager and deputy.

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. All staff we spoke with felt supported by the management of the service.

The provider needed to make improvements to their governance arrangements and where improvements had already been identified by the service.

For example, although the provider’s quality assurance system had identified improvements needed to the management of medicines, mental capacity assessments, best interest decisions and deprivation of liberty safeguards, we found actions were still required during our inspection. The provider’s governance arrangements had not identified shortfalls where topical creams needed a record of an opened and disposal date, where 1 person needed a body map for their prescribed topical cream and where another person needed improvements to their communication care plan. Where risk assessments were required for topical creams that posed a possible flammable risk. In addition, the provider’s governance arrangements had not identified where staffing arrangements during the night needed reviewing to ensure people were adequately supported with their individual needs. The provider did take immediate action during our inspection to address this and complete risk assessments for flammable creams and where 1 person needed a body map completed. Improvements were also needed to people’s individual daily documentation in their care plans.

The provider’s statement of purpose had limited information about the service such as the objectives of the services, and details of the supported living service.

However, the provider’s governance arrangements had identified some shortfalls to staff needing training it had not identified where agency staff required training in epilepsy and in supporting people within a learning disability. The service was managed by a manager and deputy that knew people and staff well. The provider confirmed they were making ongoing improvements to actions needed within the service following our inspection.

The manager and staff worked in partnership with health care professionals, so they achieved the best outcomes possible for people. People were supported by a management team who worked in partnership, so people received a seamless service. They shared information and learning with partners and collaborated for improvement. People had their views sought through monthly care plan reviews and their families’ views were also sought through surveys. The latest provider survey sent to families had all positive responses where they were satisfied with people getting safe care, good support and meaningful activities. All people were supported to attend community activities of their choice, including accessing the local shops and places of worship.

The manager had a positive culture within the organisation where they provided staff with continuous learning, innovation and improvement following incidents. They collated information about incidents and reviewed these providing any learning and training to staff if needed. Details were collated of incidents including any referrals and outcomes along with any actions taken following the incident. The provider was also able to monitor incidents and accidents to ensure actions and referrals were made as required.