Gorsefield Residential 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

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 remained requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. At our last inspection the provider was in breach of legal regulation in relation to their quality checks and overall governance. At this inspection not enough had been done and the provider was still in breach of this regulation.

This service scored 57 (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. People, relatives and staff all told us they felt supported by the management team and treated as individuals.

Not all leaders understood the context in which The service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. Although the management team and provider had links with other care providers. They had failed to promote a safe culture within the building or display the knowledge and skills in identifying and driving improvements.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. People and relatives stated they felt able to raise anything they felt was important. People were supported with regular reviews of their care and support plans and with residents meeting. People felt their views were welcomed and valued by the management team. One person said, “(Registered manager’s name) is always there if I need them. I feel I can talk with them about anything, and they will sort it for me.”

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. All staff we spoke with told us they were treated fairly and respectfully by the management team and the provider.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider did not have effective environmental checks in place to identify and drive improvements. For example, issues with the safety of the building had not been identified or addressed. The service completed an infection prevention and control check but failed to identify or rectify issues with the furnishings or high frequency touch points. When some checks had been completed these were marked as no concerns but had failed to identify the issues we found at this assessment.

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. People benefited from the providers partnership working with other health care provision in the local area. For example, good contact with GP’s, District Nurses and physiotherapy services.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. This is the fifth rated inspection where the provider has failed to achieve and maintain an overall rating of good. This meant their overall governance systems are not effective in identifying and driving good care.