Talbot Woods 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 inspection we rated this key question requires improvement. At this inspection 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 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 service 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 registered manager had a clear vision for the service. Staff understood the shared values, purpose and direction of the service. The registered manager and management team visible within the service and people, their relatives, professionals and staff told us they were accessible. There was a strong emphasis on teamwork within the service, and everyone was working towards the same outcome goals for people. A member of staff said, “Our teamwork is really good, the best.” There were clear processes in place to ensure continual improvement, to ensure the service met the individual needs of people. The service actively sought the views of people and their families through conversations and satisfaction questions. Feedback was used to shape the service.

The service 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 and manager were clear in their responsibilities to ensure people and staff were safe within the service. Learning and development were a focus for the registered manager, and they continually sought opportunities to learn and improve their own knowledge and skills and that of others within the team. People, their relatives and staff were complimentary about the leadership of the service. The registered manager had the right knowledge, skills, and experience to lead the team. Supported by a manager and senior staff. Some of the comments included: “They work very well together and make sure everything is in order”, “They are very supportive, we can say what we want. We are very comfortable saying what we need. They discuss everything with us”, “They have been very supportive, the way they continually help the staff develop their skills”, “They are so good, I really like them, they are so helpful. Our managers they are so helpful”, “The registered manager and manager are consistent and committed to the service.”

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

Staff knew how to raise concerns and speak up. There were various channels available to staff within the service, for example, to external agencies such as the local authority. The service had a ‘digital reception’ this was an electronic sign in and out tablet at the entrance to the service, this asked for feedback following a visit. Staff were confident in the registered manager and manager to address any problems they had. They told us the registered manager was approachable, and this was confirmed by people and their relatives. A member of staff said, “If we have any concerns at all we can go to the registered manager and manager, we have easy access to them.”

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.

Everyone felt included at Talbot Woods Lodge. Staff told us they enjoyed working at the service and felt accepted by their colleagues. People and their relatives told us the service was a happy place to be, they said this was due to the staff, the atmosphere, environment and the management team. We observed clear bonds between people and staff. The service was their ‘home’ and this is how everyone described it, including staff. A diverse staff team worked together to ensure everyone felt valued and accepted, staff told us their work colleagues were family. The policies underpinned acceptable practices within the service which was reinforced by staff training.

The service 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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leadership and oversight were visible within the service. People and their relatives told us they had complete confidence in the service. There had been significant improvements to governance and oversight systems, these had been embedded and sustained. Comprehensive audits and checks were in place to identify areas for development. This had included audits and checks by an external organisation. The registered manager and manager had made all notifications to CQC as required by law. A notification is the action that a provider is legally bound to take to tell us about any changes to their regulated services or incidents that have taken place in them. All audits and checks created an action plan if necessary and these had clear timescales for completion. The registered manager told us staff within the senior team all had responsibilities for audits and monitoring of the service. The registered manager and manager told us they were confident in their oversight of the service.

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.

Partnerships with external organisations were well established with the service. The service worked extensively with outside organisations, clubs, recreational places to ensure people were connected to their community. The location of the service was within walking distance of the shops, café’s, parks, bus routes and the town centre. People, their relatives and staff told us they continually made good use of their local community. The continued to make and establish relationships and a vital part of the local area.

The service 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 contribute to safe, effective practice and research.

The registered manager told us about the ways in which they were continually looking to develop the service and find new opportunities. The service had developed their digital services to enhance care recording and to support people to stay connected within their world. All feedback received about the management of the service was positive. The registered manager, manager and senior staff were confident they had safe systems and worked well as a team. They understood the importance of continual improvement within the service. The registered manager was confident their systems, processes and their own responsibilities to provide effective oversight of the service.