Davenham Hall 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 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. There was a positive culture at the service. People, relatives and staff told us they felt confident that if they wanted to raise any issues, they would be listened to. People’s loved ones told us, “They ask us for feedback when we are there. I have no cause for concern and if I did I would talk to the manager” and “I can visit whenever, and they contact me straight away if there are any issues or concerns.”

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. Staff told us they felt well supported by the managers and they were approachable.Some staff comments included, “Good manager, lots of positive changes from previous manager” and “I would immediately go to [registered manager] and the deputy, who is new to role but is very good.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were encouraged to share their views during team meetings, supervisions and staff surveys. There was a whistleblowing policy in place at the service and staff were confident to use it. There was information about how to follow the policy in staff areas. The registered manager told us they had an open-door approach, and staff could approach them at any time. We observed staff approach the management team throughout our site visits.

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. There were policies and procedures in place to ensure the provider met their legal obligations to staff and work towards a fair and inclusive culture. Minutes of team meetings evidenced staff were invited to give feedback about the service. The provider had an appropriate equality, inclusion and diversity policy.

The provider had clear levels of accountability and comprehensive governance systems to ensure people’s health needs, and the environment were regularly audited. They acted on information around risk, performance and outcomes, and shared this with others when appropriate. Staff told us about their duties and responsibilities; they told us how they managed risk and reported concerns to management. Managers and staff understood their roles, and were clear about quality performance, risks and regulatory requirements. There were checks and audits in place to monitor quality and safety. Action was taken when audits identified areas for improvement.

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. Relatives told us about attending resident meetings and some comments included, “They have regular relative meetings and feel I can talk at them” and “The have relative meetings and there is one coming up which we will attend. They ask us for feedback when we are there.”

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. The registered manager told us staff were encouraged to share ideas and explore new approaches to enhance person-centred care. Staff we spoke with confirmed this and told us they were regularly asked for feedback on what could be done better. Throughout the inspection, the management team were receptive and responsive to our feedback.