Gwendolen Road Care Home

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

We reviewed all quality statements in the Well-led domain. We identified the service had made further improvements following our previous inspection. Systems and processes to monitor the safety and quality of the care provided had improved, with clear roles, responsibilities and accountability understood. However, some shortfalls remained, with some additional learning and improvement needed within the systems and processes, namely health and safety checks, environmental oversite. The provider and registered manager accepted our findings, and immediately acted to resolve the minor issues identified during the inspection. There was an inclusive and positive culture at the service. The provider had worked hard since the last inspection to ensure they were providing person centred, and safe care. Staff told us they felt supported in their roles and were able to speak up or make suggestions to improve the service. There were systems and processes in place to monitor the quality of care. People were encouraged to be involved in their local community Relationships with partner agencies, the management team and staff had improved and feedback received supported this.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff comments about the openness, transparency and of the support they received from the management team demonstrated a positive culture and a sense of shared direction. The registered manager told us, “Everyone is treated equally here, and we all share the same values. We are confident that staff will tell you this.” All staff we spoke with confirmed the registered managers view and opinion. One told us, “We [staff] are not frightened to go to managers with anything. We’re all on the same page here. It’s a good place to work. I have worked at several other services, none of which were as good as they are here.”

Improvements had continued to be made in response to previous inspections, which had brought about a positive change to the shared direction and culture of the service. New processes put into place, which included an open door policy, increased visibility and access to managerial staff and their day to day involvement and inclusion at the service supported this change.

Staff told us they were supported by the management team and that they were confident in speaking up, sharing concerns and making suggestions. One staff member told us, “It’s not just in work we are supported it is also in our personal lives too. I had a serious personal matter to deal with at home not long ago and they were fantastic and supported me. This helped me to return to work earlier than I would have been able to without it.” Managers told us they had worked hard to make improvements and were proud of them and their achievements.

The management team engaged with external organisations and encouraged their views and feedback on performance. An open door policy and increased visibility of managers in the service and ensured people, relatives and staff could provide feedback or raise concerns confidently and promptly.

Staff told us they would confidently speak up if they needed to. Staff told us staff meetings were held regularly and they were given the opportunity to put forward their views and opinions. Managers told us they actively encouraged speaking up at meetings and supervisions.

Processes were in place underpinned by a whistleblowing policy to encourage and facilitate staff to speak up. An example of the escalation process was reviewed when a staff member had raised a concern. Staff were encouraged during team meetings to share any issues, concerns or suggestions.

Workforce equality and diversity was significantly promoted in the service. The management team ensured staff were included and made all possible reasonable adjustments on behalf of the diverse staff group from a range backgrounds, faiths and experience. Staff fasting, religious festivals/changes to hours/ gender pay gap/flexible working arrangements/ childcare arrangements/working time regulation were all considered. The registered manager and staff gave examples of where reasonable adjustments had been made.

The providers equality and diversity policy underpinned the ethos of the service. A diverse workforce had been recruited. As part of the recruitment process religion and faith practised by staff were discussed and recorded to support attendance with any events or festivals in line with reasonable adjustments. This helped to plan workforce arrangements on a day to day basis. Staff training in equality and diversity underpinned the commitment of the provider to provide an inclusive service.

The management team discussed their improved systems and processes which had increased their oversight of the service through ongoing monitoring, which included regular auditing. Actions plans were developed in response to audits, which were monitored and reviewed for progress. Staff told us in their view the service was well-led.

Further improvements had been made in response to our previous inspection. However, minor shortfalls were identified. Whilst the registered manager and provider were prompt in their response to these shortfalls, fully accepted them and resolved them during the inspection, it meant changes were needed to further improve health and safety monitoring as we found environmental checks, and some records lacked detail. The management team were able to demonstrate the areas where improvement had been made for example, introduction of a new software system, a new pre-assessment tool, safer medicines management arrangements and the formation of positive working relationships with external agencies.

People told us they received support from external health care professionals when needed. People enjoyed being involved, and were supported and encouraged to participate in events within the local community. People’s relatives spoke positively of the registered manager and staff team, which reflected the positive relationships within the service. A relative told us, “The manager is very, very nice. All the staff are very, very good. Relatives expressed satisfaction with the care provided. A relative told us, “They’ve got it right there honestly. Definitely right, and I definitely would never want to move [name].”

The management team were open and honest and spoke of the improvements they had made in response to the previous inspection and following the outcome of the local authority’s quality monitoring process. The registered manager spoke of the support they received from a dedicated team within the local authority, who had worked with them to bring about improvement.

Partner agencies who had worked alongside the registered manager, management team and staff were positive of the culture change within the service, driven in part by changes to the management team. Changes in the culture of the service had helped to improve relationships with key stakeholders including health care professionals. A social care professional told us,” In relation to person centred support, the person I am involved with does not speak English. The service has made the person’s key worker one who speaks this person’s first language and have supported them to buy food choices that are akin to their cultural food, and have liaised with family, all of which has been very positive.”

The management team were proactive in building relationships with other organisations and the local community to improve outcomes for people.

Managers told us there had been significant learning and improvement undertaken at the service. New managerial arrangements and improved systems and processes and new digital care records supported this. However, some further learning and improvement was needed. To support continued learning the registered manager took part in forums with other providers, led by the local authority and attended webinars. Staff were included more in the service, meetings were held regularly, and staff were able to feedback ideas for improvement which were taken on board by the management team. One staff member told us, "We can suggest things to the management, and they listen and take us seriously.”

The provider encouraged positive improvements and recognised achievements of individual staff through employee of the month awards. Where suggestions had been made when gathering feedback from people and relatives, action plans were drawn up to ensure these were acted upon.