Grace Lodge Nursing Home

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 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 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. For example, staff understood the providers visions and values of the service and described a positive culture within the home. Staff praised the registered manager for the improvements they had made since their appointment, including better communication systems and improved morale amongst the staff 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. For example, the registered manager understood their role and responsibilities and regulatory requirements. People and staff had confidence in the ability of the manager, their comments about the registered manager included, “Very good indeed, so caring, always wants the best for the residents,” “Excellent,” “Approachable and supportive.” and “Spot on.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. For example, staff described an open-door policy whereby they could speak with the manager anytime. People and staff told us they were confident about speaking up and their views and opinions were listened to and acted upon. A member of staff said, “[Managers name] listens to us and respects what we say”.

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. For example, the provider had an equality and diversity policy outlining their commitment to fairness, respect, and inclusion for all. Staff told us they were treated fairly and felt included and valued by the registered manager and provider. Staff shared examples of adjustments made to enable them to work flexibly.

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. For example, the registered manager had a good understanding of the providers governance systems and processes. The provider had a business continuity plan which was kept under review. Audits and checks were completed in good detail and any areas identified for improvement were clearly documented along with details of the action and timescales for completion. Safeguarding and accidents and incidents records were well maintained and included the action taken to mitigate further risk to people and others. We saw examples where a risk review was completed following events such as falls and unexplained bruising and learning from them was shared across the staff team. Confidential records were kept secure and shared only on a need-to-know basis. There was good oversight from the provider to ensure the effectiveness of their governance systems and processes.

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. For example, referrals to other organisations were made in a timely way for people to make sure they received all round care and support. This included referrals to dietitians, speech and language therapists, mental health and falls teams. Staff and leaders worked well with other external organisations. A visiting healthcare professional told us, “Staff follow our guidance and communicate well with us. Staff interactions with service users are very good, the best from the services we go in to.”

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. They actively contributed to safe, effective practice and research. For example, learning had taken place since the last inspection leading to improved outcomes for people. The provider had a service improvement plan to address areas needing improvement identified through feedback, complaints, audits and reviews.Staff were encouraged through regular meetings and supervisions to contribute to the running of the service and put forward any ideas to improve service delivery.