Archived: St Leonards Rest 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 requires improvement. At this assessment 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.

The service was in breach of legal regulation in relation to the governance of the service.

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.

Staff described a culture based on transparency, equity, equality and human rights, diversity, inclusion and engagement, and understanding challenges and the needs of people and their communities. The provider told us each individual person was at the centre of their support when decisions about their lives were being made. People were consulted about their care and care plans; relatives’ input was sought. People who chose to, were supported to access a local church.

The service 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 were knowledgeable about people’s needs. Relatives consistently told us leaders were available when they needed to talk to them. Comments included, “The manager is very on the ball,” and “The manager is lovely.” The manager was focused on enabling people to live good, ordinary lives as part of their community.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Most relatives told us they could speak up to the manager and they would respond appropriately. One relative told us, "Absolutely we can raise concerns with the management team, anything I ever questioned and anything my relative has wanted, they act on it straight away.” Staff were encouraged to raise concerns with the manager. They were confident their voices would be heard.

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. Staff told us they could speak up to the manager and they would respond appropriately. One staff member told us, “The manager is approachable and is amazing, she has put through a lot of the training for us, if it was not for her and another leader, I am not sure the care team would be as good. They are also extremely supportive. They are visible in the service, get involved and lead by example.”

Although improvements had been made following our last inspection, further improvements were required to fully meet the requirements of the regulations. Although the service had staff with some responsibilities and systems of accountability in place, governance was not always managed effectively.Systems were in place to support the manager and provider to improve and develop the service. However, audits were not always effective at driving improvement. For example, audits failed to identify and address the concerns we found relating to staff supervisions, learning from incidents, management of ‘when required’ medicines, consent to care and the environment.

The management team were responsive to some of the concerns identified and told us about the action they would take to, for example, strengthen auditing of recruitment files. We emailed the provider about our concerns relating to ‘when required’ medicines management. At the time of writing this report we had not received a response.

The service had a registered manager who had not been active in the service for an extended period of time at the time of our inspection. There was a manager in post in the service and the provider offered additional support. The appropriate notification to CQC had been completed in relation to this.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. Two healthcare professionals who work with the service were positive about the staff engagement and joint working, 1 healthcare professional told us, “They are fully engaged with us. I note the staff are always welcoming and open and transparent. I have not got any needs or worries that I need to act on.”

Leaders spoke passionately about the need for continuous learning to drive improvements for the service. They described a strong desire for improvement and shared their plans to continue improving the service. However, their systems and processes were not always operated effectively to support this ambition. For example, some staff told us the environment was difficult to work in and was cluttered. Staff had not felt empowered to act on improving the environment.

The provider had taken learning from their involvement with the local authority and have been making improvements to the service. Although the provider had systems and processes in place to identify actions to drive improvement, they were not always implemented without delay.

Following the inspection the provider told us, staff were supported when they approached management with suggestions for improvement. For instance, in relation to broadening their activities programs and suggesting menu changes.