Deer Park 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

Well-led – this means we looked for evidence that 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 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 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. Staff spoke positively about the provider’s overall purpose and culture. They told us there was a positive team working approach across the organisation. They listened to people and responded to their needs. They were proud of providing a compassionate service to people, and this positive picture of the care was reflected in comments from people, relatives and professionals. The provider’s systems and processes included a review of people’s daily care records to ensure staff were meeting people’s assessed care and support needs. There was evidence of where shortfalls were identified, this was followed up with staff. Staff meeting records confirmed how the management team had discussed complaints and actions required to improve service delivery. The manager had made improvements to the culture of the service to ensure staff felt able to report their concerns. There was improved visibility and action from the new manager. 

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. A new manager had been in post since October 2024 and told us they were going through the process to register with CQC. Staff told us management were supportive and approachable. One staff member, who had previously worked for the service and recently returned said, “Since I’ve been back, with the new manager, [manager’s name], everything is amazing. It's incredible. Now more staff, routine, structure, more caring and loving, and working as a team.” Another staff member described the manager as, “The best manager I could possibly work for, they are wonderful, can talk to them, they are on your level, get stuck in when needs to and is very approachable.” And went on to say, “[Deputy manager’s name] are really good too.” Staff also spoke positively about the regional director, administration manager and other senior staff within the service. The manager told us they had an open-door policy and spent time working on the floor. Staff confirmed this was the case and we also observed this. The manager was working on the floor when we arrived onsite.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People told us they were listened to by the manager and staff. Staff told us they had opportunities to speak up during handovers, team meetings and supervision. One staff member described a time they had raised a concern and said, “Management support is really good, they are fantastic, would feel confident to go to them if needed. Would feel comfortable raising concerns about anything.” During our assessment we found the management team were open, honest and transparent.

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. Staff told us they felt confident to be able to speak up about concerns and said they would be listened to. There was a policy on valuing and respecting diversity in the workforce. Staff confirmed the management team were fair, treated them equally and they had not experienced any form of discrimination. Staff received training in equality and diversity to raise their awareness of these principles.

The provider 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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The provider’s systems and processes to assess, monitor and mitigate risks were robust and effective. This assessment identified how staff were formally supported. Staff had received supervisions at the frequency the provider expected. The provider had investigated complaints and had taken any necessary action to make improvements. Safeguarding concerns had been reported to the local authority safeguarding team or informed CQC as required. Medicine management practice was robust. Documentation errors regarding administered or missed doses were identified in audits. Monthly medicines audits were conducted, indicating oversight. The provider had an audit process to ensure people’s care plans and risk assessments were sufficiently detailed and personalised.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners or collaborate for improvement. Overall, feedback from people and relatives was positive about the service they received. One person said, “If requested, staff would provide anything.” Staff confirmed how they worked with external professionals and how this was supportive in enabling them to meet people’s individual needs. An external health care professional was positive about partnership working. The provider’s systems and processes identified incidents people had experienced which had shared with the local authority or CQC. The manager recognised it was important that information is shared with partner agencies as soon as identified, to support people to achieve positive outcomes.

The provider 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 contributed to safe, effective practice and research. The provider had a commitment to continuous learning, innovation and improvement across the organisation and local system. The manager is a system of quality improvement initiatives whereby relevant issues such as falls, unintended weight loss, infection rates are monitored and interventions made to reduce risks and improve systems and processes based on evidence based practice. The management team have attended a variety of local forums with the local authority they worked with and attended local care meetings. This enabled the opportunity to share good practice and access specific training. The management team attended a variety of local forums and hosted community groups such as the Parkinsons Disease Awareness Support Group and a support group for carers for people living with dementia. Peoples’ quality of life was enhanced with opportunities such as attending the weekly cinema group, a ‘knit and natter’ group, the local Women’s Institute group and a local bereavement group.