Ann Challis

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 inspection we rated this key question requires improvement. At this inspection 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 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. Staff were well supported in their role and enjoyed working at the home. One member of staff said, “I’m happy working here. It’s the whole atmosphere; we’ve got a good team, we’re like family not staff members.” People and relatives knew who the management team were and felt able to speak with them if they wanted to. One relative told us, “I would talk to the manager; I have never had any issues. This place is homely and a friendly place, not intimidating.”

The service 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 provider supported their managers with development opportunities and managers told us they felt supported within their roles. The management of the service was being changed at the time of our inspection. The deputy manager was stepping into the manager role with the registered manager becoming the deputy. They said they worked well together, supporting each other during the current changes. The management team were visible within the home and staff said all were approachable and willing to assist with people’s support when needed. One member of staff said, “[Manager name] is more than willing to help on the floor.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff said they were able to speak with the managers if they needed to and said they would be listened to and any issues acted upon. Staff meetings were regularly held, with staff saying they were able to raise any ideas or issues they had. Information on how staff could raise concerns was available.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff said they were treated fairly, and everyone worked well together as a team. A member of staff told us, “We get support from the managers and directors. We’re treated fairly and our wellbeing is also supported.” Staff completed training in equality and diversity.

The service 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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate. A governance system was in place, with any actions identified being completed. The manager made immediate updates to the medicines competency checks and staff application form following our feedback to ensure best practice was being followed. Staff understood their roles and responsibilities. Incidents and accidents were reported appropriately to the local authority and CQC when required.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. For example, referrals were made to external professionals where this was required for people. We received positive feedback from the local authority quality team, who said the manager was prompt in responding to any queries they made.

The service 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 contribute to safe, effective practice and research. The management team worked well with the local authority quality teams. Recommendations from local authority visits and audits had been implemented. The manager was part of the local authority provider forums and the infection prevention and control team’s quarterly meetings.