Queens Lodge 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 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.

There was clear evidence of cultural improvement since the new general manager started. Staff consistently reported that the service had dramatically improved with one member of staff commenting, “it feels much better now” and described a positive, inclusive atmosphere where they feel listened to and valued. People and relative feedback confirmed that the service is calm and welcoming, with staff engaging in person-centred interactions. The leadership team had communicated priorities effectively and staff meetings and forums are in place to gather views.

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.

Leadership was visible, approachable and focused on improvement. Staff described the general manager as “marvellous” and “really nice and approachable,” and relatives said management has “turned the place around.” Leaders were proactive in addressing improvements needed on the departure of previous management and staff and have introduced structured systems for medication, recruitment and training. Staff confirmed they felt supported and would recommend the home as a good place to work. The general manager plans to register with CQC imminently, and there was an improvement plan in place to embed new practices.

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

Staff felt confident to raise concerns and believed they would be listened to and acted upon. Conversations with staff and inspection feedback confirmed an open-door culture and improved communication since the leadership change. Staff told us they would recommend the service to others. Systems for safeguarding and whistleblowing were understood, and staff demonstrated awareness of how to escalate 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 report there were no concerns about discrimination, and staff confirmed they feel respected and supported.

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.

Continued improvements were needed to ensure all aspects of governance oversight benefitted from the improvements made elsewhere in the service following the departure of a previous manager and staff team. While audits for medication, infection control and falls were in place, care plan audits had not been consistently completed due to the need to focus on higher priority improvements needed elsewhere within the service, such as medication management and upskilling new staff members. While overall care plans were person centred and high quality, end-of-life documentation was missing for some people. Leaders acknowledged these improvements were needed and had already included them in the improvement plan.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

Leaders worked in collaboration with partner organisations to make sure people received good quality care. Leaders worked in an open and transparent way to ensure information was shared as required to ensure people’s safety. For example, the GP visited on a weekly basis and staff worked closely to ensure those who were unwell were prioritised to the GP in advanced to ensure they could be seen.

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.

Leaders demonstrated commitment to learning and improvement. Lessons from incidents and safeguarding concerns were reviewed and shared with staff, and medication systems had been strengthened with plans to introduce electronic medication charts. While some gaps remained, such as embedding care plan audits, the provider had plans in place to continue to drive improvements.