Spencers 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 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 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. The registered manager demonstrated a passion for ensuring people received good quality, consistent support which enabled them to thrive as individuals. An open and inclusive culture was evident within the service and staff shared the registered managers passion to continually improve how people received their support.

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. The registered manager was visible in the service and knew people and the staff team very well. People responded positively to her, for example holding her hand, smiling with her and having comfortable and sociable chats with her.

Staff told us the registered manager ran the service well and treated them with respect. They said they felt well supported and were encouraged to be part of developing the service.

Relatives made comments such as, “[Registered manager] is making great strides with improvements,” and “The management is very good and visible. We are able to discuss the support of [Loved one] when needed.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People told us or indicated to us they knew who to go to if they were not happy with anything. One person told us, “We can say if we don’t like something; they’ll (registered manager and staff) sort it out. We have meetings as well.”

Relatives and staff told us the registered manager was approachable, and they were confident to raise any concerns directly with them. The provider had policies and procedures in place which guided people about to how to make a complaint. These documents were available in a range of formats so everyone could access them. Policies and procedures were also in place to guide staff about speaking out and raising issues or concerns and staff told us they were aware of those policies.

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. Staff told us they felt valued and respected by both the provider and the registered manager. The provider had a policy in place to ensure staff were treated fairly and had equal opportunities to learn and develop their roles within the organisation.

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. Systems were in place to monitor the service through a programme of regular audits. The registered manager had good oversight of the service and was supported by the provider’s Quality Team to identify and address any shortfalls in the services provided. Action plans were in place where shortfalls had been identified. The provider had recently introduced an electronic records system which we saw had improved the efficiency of the auditing processes.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 registered manager used the outcomes of audits, analysis of events and feedback from people, their relatives and staff to drive improvements within the service. The provider had systems in place to ensure learning and improvements were shared across the organisation. For example, registered managers from across the organisation met regularly with senior leaders to share good practice.