The Old Vicarage

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 service was well led and had made significant improvements since our last assessment. At the last assessment, frequent changes in leadership had impacted the consistency of oversight, communication and quality monitoring. Since then, a stable and consistent management team had been established and embedded within the service, providing clear leadership and direction for staff.

People were supported by a staff team who understood the service's vision and values and were committed to providing person-centred support. Staff spoke positively about the culture within the service and described a leadership team that was approachable, supportive and visible. Staff consistently told us they felt valued and listened to and were confident raising concerns or suggesting improvements.

The service benefitted from a stable management structure with clear lines of accountability and responsibility. Managers understood their roles and responsibilities and demonstrated a good understanding of the needs of people using the service.

At our last assessment, concerns had been identified regarding inconsistent leadership and management oversight. Since then, the registered manager and management team had implemented a range of improvements to strengthen governance, quality assurance and staff support arrangements. The manager and staff demonstrated a commitment to continuous improvement and were able to clearly describe service developments that had taken place in response to feedback, incidents and audits. Improvements made since the previous inspection included strengthening medicines management processes, improving staffing deployment arrangements and developing governance systems to provide greater oversight of quality and safety.

The management team promoted equality, diversity and inclusion and understood the importance of delivering support that respected people's individual needs, backgrounds and preferences.

There was a positive and open culture within the service where people, relatives and staff were encouraged to share feedback and raise concerns.

Staff told us they felt comfortable speaking openly with managers and were confident concerns would be listened to and addressed appropriately. Staff understood whistleblowing procedures and knew how to raise concerns both within the organisation and externally if required.

One staff member said, “[Registered manager] always has time for us and listens, I know they would act immediately on any concerns.” Relatives told us they knew who to contact if they had concerns and felt their views were valued. Feedback demonstrated improved confidence in the service's communication and responsiveness compared to the previous inspection. One relative said, “The home is definitely more responsive to any issues or concerns, but these have all reduced. I am very happy with everything.”

The provider promoted a culture of equality, diversity and inclusion where staff felt respected, valued and supported regardless of their background, characteristics or personal circumstances. Managers were committed to creating an inclusive workplace and demonstrated a clear understanding of the importance of diversity within the workforce.

Staff told us they were treated fairly and with respect and felt comfortable being themselves at work. They said managers promoted an open and inclusive culture where differences were celebrated and individual contributions were recognised. Staff described positive working relationships within the team and told us they felt supported by both colleagues and managers.

Equality, diversity and inclusion were considered throughout recruitment, induction, supervision and ongoing workforce development processes. Staff received training to support their understanding of equality, diversity and human rights, helping them to provide respectful, person-centred support to people using the service.

The provider had established effective systems and processes to monitor the quality and safety of the service and drive continuous improvement.

At the previous inspection, governance systems had not always been effective in identifying repeated concerns or ensuring timely action was taken. In particular, oversight of medicines management, staffing deployment and incident analysis had lacked consistency. Since then, significant improvements had been made.

There were robust auditing systems in place covering key aspects of service delivery, including medicines, incidents and accidents, safeguarding, health and safety, staffing, training and care planning. Audits were completed regularly and actions were monitored to completion through management oversight processes.

The registered manager was aware of the lack of information being recorded within daily notes by staff as they delivered care and supported people. There was an action plan in place to support and upskill staff to make improvements.

The provider worked effectively with a range of external partners and community organisations to promote positive outcomes for people. Staff and managers maintained positive working relationships with healthcare professionals, learning disability specialists, social workers, commissioners and other agencies involved in people's care. Professional recommendations were acted upon and incorporated into people's support plans where appropriate.

Professionals spoke highly of the provider's commitment to improving people's quality of life and working collaboratively to achieve positive outcomes. One professional told us:

"The provider always focuses on what is best for the person and has a real commitment to positive behavioural support and reducing restrictions where possible by improving quality of life. The registered manager is committed to their staff team and providing support to them too and has gone the extra mile in terms of advocating for some of the people they support. An example was a person who needed a lot more input from primary care services, and the registered manager really pushed hard to get them the support needed."

This feedback demonstrated the service's commitment to person-centred care, positive behavioural support principles and ensuring people had access to the services they needed to maintain their health and wellbeing. It also reflected the positive relationships that had been developed between the service and partner agencies.

The service had developed a culture of learning and continuous improvement. Improvements identified since the previous assessment demonstrated the provider's commitment to learning from experience and strengthening service delivery.

Accidents, incidents, safeguarding concerns and complaints were reviewed by managers to identify learning opportunities and areas for improvement. Systems for analysing information had improved significantly since the previous assessment, enabling the management team to identify trends, implement actions and monitor the effectiveness of changes made.

Examples were seen where investigations and reviews had led to changes in practice, additional staff guidance, improved risk management and enhanced oversight processes. Learning was shared with staff through meetings, supervisions and day-to-day management support.

The provider understood and fulfilled their responsibilities under the Duty of Candour. Where things had gone wrong, there was evidence of openness, honesty and appropriate communication with people, relatives and relevant agencies. Records demonstrated incidents were investigated appropriately and action was taken to reduce the likelihood of recurrence.