Abbeyfield Loughborough

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 changed to 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 management team and staff had a shared vision and culture based on listening, learning and trust. The management team were visible, knowledgeable and supportive, helping staff develop in their roles. Most staff felt supported to give feedback and were treated equally. There was a positive atmosphere and culture in the service which focused on effective care and support for people.

The management team were knowledgeable about their regulatory responsibilities and about the priorities for the development of the service.

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 registered manager was visible in the service, approachable and accessible for people and staff. One relative told us, “The registered manager is absolutely great and gives time to everybody. They are very reassuring and approachable, and their office is just by the entrance, and they will often call out as you come in to acknowledge us.”

The management team had the required experience, skills and knowledge to manage and lead the service. During the assessment they were open and honest about the challenges they had faced and were positive about the improvements they had made.

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

There were processes in place to allow people, relatives and staff to raise concerns and / or share ideas. People and their relatives told us the registered manager was very approachable and addressed any concerns they had immediately.

Staff felt confident to raise concerns with people outside of the organisation such as GPs to safeguard people they cared for.

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.

There was a policy in place to protect staff from harassment and bullying and a focus on protected characteristics under the Equality Act. The registered manager had developed an inclusive workforce and recognised the value of diversity amongst the team.

Most staff felt respected, supported, and valued. They said the service promoted equality and diversity in daily work and provided opportunities for development. They could raise any concerns without fear.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance.

Although there had been improvements in the systems in place to monitor the quality and safety of the service, there were still further improvements needed to ensure the systems were fully effective. For example, although medicine audits were in place they failed to identify the discrepancies in the fridge temperature monitoring found during this assessment.

There were a wide range of audits and checks carried out by the provider and registered manager. Audits included, incidents and accidents, medicines, care plans, and health and safety. The audits identified areas of improvement and had action plans.

In addition, a service action plan was in place which incorporated actions identified through these systems.

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 provider and staff shared the same goal to provide positive outcomes for people. The registered manager encouraged staff to discuss and share ideas for improvement and innovation. An external stakeholder told us, “The manager communicates well with us. They reach out for support if they think we can help, and they get in touch if they need to report something.”

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.

There was evidence of positive changes that had been made to the service since our last assessment.The provider made the decision to close Ingleside, an additional part of the service, which reduced their maximum capacity, to enable a more focussed and effective implementation of the required improvements.

The provider had suitable systems and policies to ensure learning and improvement. We noted lessons learnt were in place and where concerns had been identified these concerns were shared with the staff team. The registered manager was responsive to feedback from all sources and had several ideas on how to continuously improve the experience for people living at the home.