Courtfield Lodge

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 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.

The home had a mission statement, which documented the company’s core values as family, honesty and respect: “Our approach is tailored to individual residents, Person Centred Care in its truest form.”

There was a new manager at the home. They had held meetings with each team within the home. During these meetings praise for work well done was given, the manager also respectfully made her expectations clear, that quality within the home needed to be improved. The meetings offered the opportunity for staff to feedback and discuss areas of concern and improvement they felt necessary.

A daily flash meeting was introduced including members from each team so issues could be identified and dealt with promptly.

A staff member told us, “There are daily meetings to talk about any changes or to ask if we need anything, changes about residents, any safeguarding’s, hospital or new admissions are discussed with us”.

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 manager described how they had felt well supported through their induction into the home, with daily support from the area manager, they told us, “I can say, I’ve been well supported.”

Leaders at all levels are visible and available. They lead by example modelling open and inclusive behaviours. All the staff we spoke to felt supported by the management team.A family member shared, “The manager may be new, but she has demonstrated that she knew everything about [person] and their needs.”

Managers and leaders understood the requirements and recommendations made by the CQC. They kept up to date with all relevant changes and communicated these effectively to their team.

The management team spoke positively about the home, the deputy shared, “I am proud to work here, and I am enjoying seeing the improvements happen.”

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

The culture within the home was for people to have the freedom to speak up and processes were being evolved to support this.

There were regular staff surveys staff could complete anonymously; results were analysed by head office and results shared with the home. Results provided a benchmark target and identified how close the home was to the target. The latest survey showed that staff felt able to speak up in team meetings and that management were approachable and listened to concerns.

All staff we spoke to said they felt able to speak to the new manager, they described that they felt there was an open-door approach. They told us, “The manager is easy to talk to,” and “I’m confident to ask for help.”

The staff handbook had links to the complaints procedure, safeguarding and whistleblowing policies.

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.

Several staff members were employed from overseas. The appropriate checks were in place, and any conditions of sponsorship were being met by the provider. Appraisals were being prioritised for oversees staff to ensure continued adherence with requirements.

There had been some staff changes due to previous poor practice, now staff commented positively on the good atmosphere at the home, and how helpful and nice the team was.

The home worked to support staff. A staff member told us, “They have made reasonable adjustments for me which have helped me stay in work.”

The staff handbook detailed the rights all staff could expect regarding equal opportunities through all areas of employment including recruitment, training, development and promotion it also contained links to the Harassment Policy and Procedure.

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 manager and deputy manager conducted various daily, weekly and monthly checks to ensure they had good oversight of the home. The owner made unannounced visits quarterly, conducting home inspections and giving feedback/actions following his visit.

There were systems in place to audit health and safety, IPC, and medication. Care interactions were recorded digitally and alerted the manager to any upcoming or missed tasks.

The provider’s business continuity plan detailed their preparedness for emergencies and adverse events.

The manager submitted statutory and regulatory notifications in a timely manner as per regulatory 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.

The home worked with a local Care in the Community service which meant that some people were invited to social events and a community café. Several people also attended a knit and natter group, and this had been expanded to a crochet group to open up accessibility.

The home had a good relationship with the neighbours, some of whom had helped out during the fire at the home.

Members of the management team had attended the local authority forums and there were plans for the new manager to attend more.

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 and leaders have a good understanding of how to make improvement happen. The approach was consistent and includes measuring outcomes and impacts.

Audits in use were detailed and included action to be taken, priority level, and details of any progress made.Regional manager and health and safety manager conducted their own audits on a Quarterly/Biannual basis.

There was a maintenance schedule which included repairs needed and decoration schedule.

The leadership team were aware of where previous issues had been experienced and were operating a “lessons learnt” process to improve practice.

The home had invested in new technologies such as digital care records, EMAR and a pain scoring app to assist in better outcomes and information sharing between the provider’s different homes.