Lanercost House - Carlyle Suite

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, equality, diversity and inclusion, and a clear understanding of the needs of people using the service and the local community.

The registered manager described the core values of the service, telling us, “The key values of the service are respect, honesty, integrity, kindness and encouragement. I want a consistent, happy staff group and I want the residents to feel happy and content.” What we observed during the inspection reflected these values in practice. There was a positive and welcoming atmosphere throughout the home, and staff consistently interacted with people in a kind and caring way.

Staff spoke positively about the culture of the service and the support they received from colleagues and leaders. One staff member told us, “I love coming to work, one of the best places I've worked, lovely atmosphere.”

Health professionals also shared positive views about the culture. One told us, “It’s really good, staff all have respect for one another and work well as a team.”
 

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.

Management presence within the service was strong, consistent and visible. One staff member old us, “Management are really thorough, daily walk rounds are thorough. Flash meetings take place at 11am where all units learn from each other. Leadership here is excellent... We can ask for things to improve and they are accommodating.” Another staff member said, “Managers are supportive. If we ever have any issues [registered manager] and [deputy manager] are always available. They listen and we can approach them any time.”
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were aware of the term freedom to speak up.

The registered manager actively promoted a positive and open “speaking up” culture within the home, where staff felt encouraged and supported to raise concerns, ideas or feedback. Everyone we spoke with told us they felt confident to speak up if they had any concerns and were reassured that these would be taken seriously and acted upon. One staff member told us, “If I had any problems or saw poor practice, I'd feel confident reporting it to the manager.” Another staff member said, “I go to the morning meetings, staff meetings and supervision meetings. I also get a ‘my voice’ survey. I feel like [management] listen when I raise issues. I've got plenty of support.”

A whistleblowing policy was in place which contained information to guide staff. When we asked the registered manager about whistleblowing, they said “I'd make sure everything was addressed in a safe and protected way. I would welcome staff to raise concerns, and I would always protect the person raising concerns.”
 

The provider valued diversity within their workforce and promoted an inclusive and fair culture. Systems were in place to support equality and ensure staff were treated with respect.

The management team actively sought and considered staff feedback through a range of methods, including surveys and team meetings. This helped leaders understand staff experiences and promote a positive and inclusive working environment.

One staff member told us, “It is a really lovely care home. If my family ever needed care, I would recommend it. The culture is really good, and we have a great team.
Staff did not raise any concerns regarding equality, diversity or inclusion during the inspection, and feedback indicated staff felt supported and treated fairly.
 

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

A range of audits and quality assurance systems were in place and used to monitor the quality of care. However, these were not always effective in identifying all the issues found during the inspection, including gaps in some risk assessments, inconsistencies in care planning and aspects of medicines management. The registered manager acknowledged these findings and demonstrated they had already begun to review and strengthen governance systems to ensure greater oversight and reduce the risk of similar issues being missed in future.

Systems were in place to review incidents and promote learning. For example, there was a clear post-falls procedure, and analysis of falls was reviewed by the leadership team. Staff told us, “Any learning from incidents or falls is handed over at handover or communicated to staff in huddles.”

The leadership team held regular clinical governance meetings where key areas such as incidents, safeguarding, infection prevention and medicines were reviewed. Records showed these meetings were structured and supported oversight, learning and service improvement.

Staff and leaders described a well-resourced service. The registered manager told us they were supported to make improvements where needed, and one staff member said, “The residents really are well looked after. The management is supportive. There is always money available to pay for improvements.”
 

The provider understood their responsibility to work in partnership with others to ensure people experienced coordinated and seamless care. Information was shared appropriately, and staff worked collaboratively with partner organisations to support good outcomes for people.

Leaders worked closely with health professionals and services to ensure people received safe and effective care. This partnership working supported timely communication, shared decision-making and continuity of care.

The provider also promoted links within the local community to enhance people’s experiences and reduce social isolation. The registered manager told us, “We want The Carlyle Suite to be busy and to keep people in the community, we don’t want people to be sat watching tele. We take group activities into the community and people from all communities come to hosted events here. We recently invited people from another local care home for a tea dance.”

This approach helped people remain connected to their community and supported their wellbeing through meaningful social opportunities.
 

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.

The provider had invested in systems and technology to support improvements in care delivery. For example, a personal interaction response (PIR) system was used to alert staff when people required support. Leaders had clear oversight of this system and regularly monitored response times, which showed staff responded promptly to people’s needs.

The provider had also introduced dementia-friendly interactive technology, which we saw people using with support from staff. This supported engagement, stimulation and wellbeing.

There was evidence of learning from complaints, safeguarding concerns, incidents and accidents. This learning was shared with staff to support improvements in practice and help reduce the likelihood of similar issues occurring in the future.

The provider remained open and transparent throughout the inspection process, and both the registered manager and leadership team showed a strong willingness to respond to and learn from any concerns identified.