George Potter House

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 now consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

However, the service remains in breach of legal regulations in relation to their quality monitoring systems to ensure they are effectively managed. This was identified as an issue at the providers last assessment. At this assessment we found not enough improvement had been made because the providers governance systems remained ineffective as they failed to pick up and/or address several new issues we identified during our site visit. This included medicines not always being stored securely and peoples risk assessment and management plans either not being accessible or sufficiently detailed, up to date or accurate.

This represented a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the evidence category findings below.

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.

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 were supported by managers to deliver person-centred care and support to people in line with the provider’s vision and values for the service. The new managers had a clear vision for the service and told us they routinely used individual and group meetings to remind staff about the provider’s underlying core values and principles. An external care professional told us, “We feel the new leadership has been taking steps towards supporting and modelling a safe culture where staff feel safe to raise concerns.”

The provider 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 service had a new management team in place, led by an acting manager who had applied for registered manager with the CQC. Both the acting manager and deputy manager were suitably experienced and qualified.

The feedback we received from people about how the service was now managed was positive. People told us the new managers were always accessible and approachable. Typical feedback included, “The new managers are really managing the place well and doing their utmost to make improvements as quickly as they can”, “[name of managers] are both firm but fair. We have regular meetings with them, so we know they continue to enforce change for the better at George Potter House and recognise when staff need to be performance managed or should be rewarded for their good work” and “We’re very impressed with the new leadership with their clinical background and extensive care experience. They’re changing the care home for the better”. Staff were also positive about the leadership approach of the managers who they consistently described as effective, professional, and friendly.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Managers encouraged an open and transparent culture where people living at the care home, their relatives, external health and social care professionals and staff were encouraged to raise concerns and without fear.

People told us they felt comfortable raising concerns with the managers and felt listened to. A relative said, “The managers are very receptive, and their doors are always open to the residents and their families. I had some concerns, so we had a meeting with the management who listened, were empathetic and took prompt action to resolve our issue.”

Staff were equally complimentary about feeling able to speak up and have their voices heard. Staff told us there had been a positive change in the culture of the care home since the new managers had arrived. They said they would not hesitate to raise any concerns directly with the management team and said they were more confident their concerns would now be heard. A member of staff remarked, “[Name of acting home manager] doesn’t want us to bring each other down, she wants us to work as a team.” Another member of staff added, “We couldn’t really speak to the previous managers but you can certainly talk to the new lot [managers].”

The provider used a range of methods to gather the views of people using the service and staff about George Potter House. This included, regular care plan reviews, staff handovers between shifts, and various heads of department, clinical risk, and individual and group meetings with people living in the care home, relatives and staff. In addition, the acting home manager told us they had recently introduced a focus group of senior staff who provided feedback to an external company about their experiences of working at the care home. The feedback received was positive about the impact the new managers had on the culture at the service.

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.

We undertook this assessment partially because we received concerning information alleging there was a discriminatory and bullying culture at the care home.

Staff were positive about the leadership approach of the new managers who they said treated them equally and fairly and were always supportive. Staff told us their views were now respected by managers and they felt like valued members of the team. A member of staff remarked, “The new managers are both approachable and supportive. I’m happy to come to work now, which I wasn’t before they [new managers] came.” A second member of staff added, “The new managers are much better at asking us how we’re doing and encouraging us to speak up. Previous managers ‘gagged’ us and our views were often suppressed. It’s a lot happier place to work these days.”

Managers understood the importance of having a fair and inclusive workplace for all staff to work in. Staff were provided with enough support through relevant training and supervision to inform their knowledge and understanding of equality, inclusivity and fairness in the workplace.

The service did not always have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

At this assessment we found the provider had made some improvements in relation to how they now operated their governance systems, but not enough. This was because they still failed to pick up and/or take appropriate action to address several new issues we identified at this assessment. This included issues we found in relation to medicines not always being stored securely and the quality of information recorded on people’s records not always being sufficiently detailed, up to date and/or accurate.

However, we positively noted the overall quality and safety people received was routinely monitored by managers and staff. The provider regularly conducted audits and checks, the outcomes of which were routinely analysed to identify issues, learn lessons and develop action plans to improve the service they provided people. These quality assurance systems had indicators that identified how the service was performing, areas requiring improvement and areas where the service was achieving or exceeding targets. We saw the provider had developed an improvement plan and were continually taking action to make the care home better.

Managers understood their responsibilities in relation to their regulatory requirements around notifiable incidents. Our records told us that appropriate, timely notifications were made to the CQC.

We saw the service's previous CQC inspection report, which was clearly displayed in the care home and was easy to access on the provider's website. The display of the ratings is a legal requirement, to inform people, those seeking information about the service and visitors of our judgments.

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 shared information and learning with partners and collaborated for improvement. Managers and staff told us they worked closely with various external health and social care professionals and bodies who they regularly consulted and welcomed their views and advice. External health and social care professionals said they had noticed a clear improvement in the working relationship with this provider since the new managers had been in post. An external care professional remarked, “The managers are working much closer with us these days and we have a much better relationship with them.” Another added, “The new managers always take on board our advice towards improving our client wellbeing and health.”

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.

Managers recognised the importance of learning lessons and continuous improvement to ensure people living at the care home received good quality care and support. Managers told us all the audits and checks the provider conducted were routinely analysed to identify performance shortfalls and learn lessons, so the service could continuously improve. Staff confirmed information about any lessons learnt were always shared with them during individual and group supervision meetings with their line managers.