Delaheys 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.

This is the first assessment for this location under the new provider. This key question has been rated 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 told us the aim of the service was to provide a culture of person-centred care. The service shared a culture of kindness, respect and dignity, this was observed during inspection. Staff interacted with people in a friendly and kind manor and included the use of laughter. This showed how well the staff knew people.

The management team were focused on driving up learning opportunities for all staff and building their confidence as leaders, regardless of their specific role. This included introducing champion roles. Staff reported feeling listened to through regular team meetings, notices, and emails, and felt their ideas were acted upon.

Staff were very happy within the team. A staff member said, “We all pull together; it’s a proper team effort.” This indicated a positive environment.

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.

Leadership was visible, approachable and focused on improvement. Staff described the registered manager as “supportive” and “very organised and motivated, a good manager who motivates others and that’s what we needed.” Another member of staff said, “I am confident in the management team, and they listen to my ideas and also help me to improve.”

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

A whistleblowing policy was in place. Staff said they would feel confident to raise any issues, and these would be listened to and acted upon. Where lessons had been learned following investigations or concerns, these had been shared with staff to make sure improvements were made and maintained.

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 valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for staff who worked for them. Staff had no concerns about discrimination, and staff confirmed they felt respected and supported.

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.

Leaders had a good awareness of and understood what their role involved. There were appropriate business plans and contingency plans in place. There was a thorough schedule of audits including medicines, environmental and infection control audits to monitor quality.

The registered manager sent statutory notifications to relevant agencies which is their legal responsibility 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.

Leaders worked in collaboration with partner organisations to make sure people received good quality care

The service had several links to the local community. For example, Holy communion was offered every Sunday, and people were assisted to attend church when requested. There were also links with dog therapy, local musicians and a ‘moves with music’ group, all of which improved people’s links with the local community.

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.

Leaders demonstrated commitment to learning and improvement. Lessons from incidents and safeguarding concerns were reviewed and shared with staff. Recent improvements had been implemented to add reversible causes to care plans where people had ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) in place. Learning was shared effectively across the provider’s other locations to ensure transparency. Staff were encouraged to reflect on their performance and group supervision was used to share good practice and to reflect on lessons learned.