Telford Court Nursing 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. At our last assessment we rated this key question good. At this assessment the rating has remained 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 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. The registered manager was proud of the positive culture at the service. Staff told us they were given guidance and felt able to make any suggestions. One staff member commented, “We’re like one big happy family.”

The provider had inclusive leaders 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 registered manager who was supported by a management team. Everyone we spoke with including people, relatives and professionals were very positive about the management of the service and indicated the registered manager was supportive and approachable. During our on-site visit, they were open, transparent, and responsive to our feedback about the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistleblowing policy in place. People were confident that if they were to complain, their concerns would be taken seriously by staff. People's feedback was sought through meetings and surveys. Staff were given opportunity to share any concerns or issues.

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 described an inclusive culture, where they were treated fairly.

Overall, the provider had clear responsibilities, roles, systems of accountability and governance systems in place. The management team had a ‘hands on’ approach, which they believed helped them to have a good understanding and oversight of the service. The registered manager had an organised system of audits, checks and analysis, which was routinely carried out to monitor the quality of the service. However, the provider’s oversight had not identified that CQC had not been informed of every notifiable incident as required, although these had been addressed. The registered manager has subsequently submitted the correct notifications. There were aspects of record keeping which needed to be more accurate and scheduled reviews undertaken. The registered manager was aware of and addressing the other areas we highlighted. They told us they would introduce a regular check, in relation to call bell responses. Prior to our visit the provider told us they had been planning to arrange a mock inspection.

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. They worked closely with partners to support people coming out of hospital or from home with recovery and assessment of their ongoing support needs, focused on rehabilitation. Visiting professionals were complimentary about the service and told us staff were knowledgeable and responsive to people’s needs. The provider was involved with the wider community with links to local schools and churches. There was a community coffee morning each month. An external dementia specialist nurse had undertaken sessions to support people and families with information.

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 registered manager shared medication updates and alerts with staff. The provider had changed to a new pharmacy and taken part in an external audit to continue to learn and develop. The provider had acted on feedback from people and relatives in relation suggestions to improve the service. For example, they had made alterations to some of the lounge areas to make them feel more homely. The provider had introduced a new cinema room which was ready for use.