Lansdowne Road (67-71)

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 rated inspection (publication date 23 October 2023) we rated this key question Good. At this inspection 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 68 (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 provider’s vision and values were displayed within the service and known, understood and met by staff. There was a positive staff culture of openness and transparency. Staff spoke highly of their work and with respect and compassion for the people they supported.

The provider had an inclusive culture. For example, a person who lived at the service attended the provider’s regional meeting. This representation ensured that people who used the service had a direct voice in the organisation’s decision- making. It also demonstrated the provider’s commitment to equality, diversity and person-centred care.

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 experienced and greatly liked by people, relatives and staff. Staff praised the registered manager for their support, approachability, and kind and caring manner.

The registered manager was supported by an experienced deputy manager, administrator and competent senior staff and a dedicated, caring and compassionate staff team. The provider’s senior leadership team regularly attended the service and provided oversight, leadership and guidance. The registered manager was positive about the support they received.

The management team were open and honest throughout the inspection and where shortfalls were identified immediate action was taken to make improvements.

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

The provider had policies and procedures to support the staff team to report poor practice. Staff confirmed they were aware of these and understood their responsibility to protect people and told us they would not hesitate to use them if required. This information was displayed for staff.

Staff received opportunities via a survey to give their feedback about working at the service including what’s working well and any concerns.

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.

The provider had policies and procedures in place to protect staff’s human rights and working conditions. This included a Flexible Working policy. Staff could also opt out of the working time directive, enabling them to work additional hours if they wished. This was monitored by the management team to ensure staff wellbeing. The staff rota took account of staff’s shift and work pattern preferences.

The provider valued diversity within the staff team and demonstrated a commitment to supporting and recognising staff contributions.

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.

At the last inspection, concerns were identified in the provider’s systems and processes that assessed, reviewed and monitored quality and safety. This inspection found sufficient improvements and the breach in regulation was met. However, as reflected in this report some shortfalls were found during this inspection. Whilst this had not had a negative impact on people, and the registered manager took immediate actions; it highlighted a further review of governance procedures were required. Following our inspection, the registered manager and operations director provided further assurances of actions taken to strengthen their systems and processes.

Staff were positive about working for the service. Since we last inspected, improvements had been made to support staff in developing a greater understanding of their role, responsibilities and accountability.

The registered manager had met their registration regulatory requirements of submitting notifications to the CQC of reportable incidents they are required to do so.

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.

Staff worked with external health and social care professionals. This was evident from people’s care records that confirmed there was a collaborative approach and recommendations made by external professionals were implemented.

Feedback from external professionals was positive about how well people were supported to maintain their safety and experience positive outcomes.

We received sufficient assurance that the provider was meeting the requirements of CQC’s Right Support, Right Care, Right Culture guidance. This guidance was prominently displayed within the service, supporting both staff and people using the service to understand the expected quality-of-life standards. As reflected throughout the report, people led active and fulfilling lives where their individuality was respected and celebrated. People experienced physical activity, personal choice, social engagement, and a sense of purpose.

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. Whilst improvements had been made at the service since our last inspection, this was an area for further development to ensure new and improved ways of working were fully embedded and sustained.

The management team attended internal management meetings that provided opportunities of shared good practice and learning across the organisation. The management team also attended local authority and other provider forums and received updates that kept them informed of new and improved best practice guidance and changes to legislation.