Leazes Hall 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 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 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 demonstrated the necessary skills and experience to lead the service effectively, with a focus on priorities and a transparent, open approach throughout the assessment. Minor areas of improvement identified during this assessment were responded to quickly and responsively.

Staff had a good understanding of their roles and shared the registered manager’s commitment to providing person-centred care and treating and valuing people as individuals. Staff told us they contributed to a kind and supportive culture at the service. A range of policies were in place to guide staff.

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.

The registered manager had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. People were very positive about the registered manager and the way the home was run. They described the registered manager as approachable and supportive. One person said, “[Registered manager] is very good. They’re ‘no nonsense’, but they seem fair and really know everyone. If there was a problem I know they would sort it out.”

The management team worked well together and supported each other to deliver safe, quality care. Several staff told us they had worked there for several years and wouldn’t work anywhere else as they felt valued. A staff member told us, “The registered manager is approachable. They’ve got high standards and expect the same from the staff team, but they’re fair."

The provider fostered a positive culture where people and staff felt they could speak up and their voice would be heard. The provider had a whistleblowing policy in place and staff understood their responsibilities to raise concerns when needed. Staff were confident raising issues with management and felt they would be listened to and acted upon.

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. Systems were in place to encourage staff feedback, through staff meetings and supervisions. Policies and procedures promoted an equitable workplace.

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

The provider visited the service often and frequently met with the management team, but records did not consistently capture effective oversight by the provider. Governance processes needed to include how the provider identifies and generates improvements within the service.

Governance systems which were overseen by the registered manager were effective. The minor issues we found during this assessment were responded to appropriately and promptly during and following our visits.

The registered manager understood their responsibility under duty of candour to be open and honest when things went wrong. Information about relevant incidents at the service was submitted to CQC in line with legal requirements.

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. Healthcare partners did not raise any concerns about how the service worked in effective partnership with them.

There were strong links with commissioners and the local authority, and the registered manager used these relationships to share learning and drive improvements. The service also supported access to advocacy services where needed, ensuring people’s voices were heard.

People were supported to remain active members of their community through a range of regular outings, events and meaningful activities. Relatives were welcomed and encouraged to be involved in daily life, helping to maintain strong relationships and continuity of care.

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. Staff received regular training, and good practice was shared and discussed at regular meetings.

The provider was investing in an electronic care records system, which they hoped would make sharing information with other professionals easier and enable staff to spend more time supporting people. This was in the early stages, but a significant amount of information had already been transferred onto the electronic system by the deputy manager, who was leading on this project.