Letheringsett Hall

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 changed to Requires Improvement: This meant the 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 Good Governance.

This service scored 61 (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, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff told us they felt supported. One staff member said, “Management at Letheringsett Hall are very approachable and hands on if ever needed. I would not hesitate to contact either party if I feel I needed to.”

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. Relatives told us they felt confident raising any concerns with the managers and believed they would be listened to. One relative said, “The manager is very friendly. I have had no need to raise any concerns.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff reported that the registered manager was approachable. One staff member told us, “I feel confident in my role, and I feel we all work well as a team.” Regular staff meetings helped keep everyone informed, and the discussions showed that the team communicated well and reflected on lessons learned to improve the service.

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. We observed staff worked well as a team. Staff had received equality and diversity training as part of their mandatory training. Staff told us, “I feel staff morale is good and that we are happy in our work and with our colleagues, which then impacts on our service users and their families, which makes a happy home for all.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider had systems in place for the oversight of the service, however, these were not used effectively. We identified concerns during this assessment in relation to fire safety and care plans and risk assessments containing contradictory information. This demonstrated that the existing checks such as audits carried out by the management team had not been conducted thoroughly. Therefore, the providers governance systems had failed to identify and address risks found. As a result, people did not always receive personalised care that was fully responsive to their individual health needs.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. The provider did not always share information with the relevant authorities.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research. Existing audit processes did not capture the issues identified during the inspection, which meant the service was unable to use this information to drive improvement or embed learning. However, national incidents highlighted in the media were discussed in staff meetings, providing opportunities for staff to reflect on practice and consider lessons learned.