The Spires

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 good governance for failure to identify concerns around medicines and people’s care records. At this inspection we found the provider had not sustained improvements and therefore remained in breach of regulation for good governance.

This service scored 62 (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 feedback about the culture and shared direction of the service was positive. Staff felt involved and engaged in the day to day running of the service. Several staff highlighted the improvements which had been made and how their enhanced teamwork had positively impacted on people's experiences. Staff told us they embedded the values of the home through discussions, including daily team meeting where heads of department met and shared key information. The registered manager also said there had been improvements in the culture of the home.

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. Staff spoke very positively about the registered manager. They said the registered manager was supportive and approachable and felt they had developed a positive culture through good teamwork. The registered manager and provider representative were receptive to feedback throughout the assessment process and took action where we highlighted shortfalls. For example, where there were shortfalls in care records, they updated them promptly and provided evidence to the assessment team. There were processes in place for the registered manager to communicate with people, relatives and staff. There was inconsistency in the quality of records, how and when information was recorded and the accuracy of information recorded. We discussed this with the registered manager and provider representative who confirmed they would address this. The registered manager demonstrated they were open and compassionate throughout the assessment process, and this was corroborated by staff and stakeholders.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were aware of the processes to raise concerns and felt empowered to speak openly. They told us they were confident to raise concerns outside of the service if they needed to. A staff member described how they had raised concerns with the registered manager and these had been listened to. The registered manager told us these concerns had been acted on but had not shared a response due to confidentiality. Regular staff meetings took place and there was evidence of good attendance and staff involvement.

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 and managers spoken to strongly identified with a shared commitment to good practice and an open approach to problems and issues. Staff felt well supported in doing their jobs and spoke positively about teamwork, shared values and care for people. They felt their colleagues, managers and the company supported them. Staff described management support for them to achieve a good work-life balance, and care and flexibility when health or family circumstances required it. New staff described a welcoming, supportive and inclusion culture which enabled them to feel comfortable and confident in their roles.

The provider had clear responsibilities, roles, systems of accountability to support governance but these were not followed or used effectively to ensure full oversight of the care provided. Audits to monitor the quality of the service were regularly completed and action plans created and reviewed. However, they had not identified multiple shortfalls we identified as part of the assessment. We found no evidence that people had been harmed. However, systems were not robust enough to demonstrate good governance. This placed people at risk of harm. There had been improvements to the provider's auditing processes. For example, people's weights were clearly monitored, and action taken when required. The registered manager completed a regular care plan audit, but this lacked detail. Care plans were reviewed monthly but were inconsistent with gaps in records. We did not identify serious concerns in relation to the impact on people but the provider remained in breach of regulation.

The provider understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement. Staff followed clear and effective systems and processes which demonstrated effective partnership working within the service's staff team, as well as with external professionals and partners. A health professional told us, “The home is lovely, the residents are looked after so well and staff follow guidance well. One of the best in the area. There are no shortfalls”. There was good evidence that staff worked as part of the community with links they had forged with local community groups, including places of worship and cultural groups.

Whilst the provider was focused on continuous learning, innovation and improvement across the organisation and local system, the changes they had made required further embedding to ensure improvements were sustained. There had been improvements to auditing processes but further improvements were required to ensure these were embedded and areas where we found shortfalls were developed fully. The provider shared learning and best practice with registered managers across their services and provided specialist support and guidance where this was required. For example, specialist dementia guidance and clinical support.