Drumconner Lancing

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 inadequate. 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.

Theproviderwas previously in breach of the legal regulation in relation to governance at the service and of their regulation conditions. Sustained improvements were found at this assessment, and theproviderwas no longer in breach of this regulation.

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.

Leaders promoted respectful, safe and dignified care, with clear expectations embedded through induction, supervision and team meetings. There was an open and honest culture where learning from mistakes and continuous improvement were encouraged. Since the last inspection, leaders and staff had worked collaboratively to drive and sustain improvements across the service. There was a shared commitment to improving outcomes for people, with staff demonstrating openness, accountability and willingness to learn. Leaders promoted a proactive learning culture where feedback, reflection and teamwork were used positively to strengthen practice and maintain progress.

Staff felt valued, people felt included and visitors felt welcomed through regular engagement and visible leadership. A person told us the manager was, “A nice lady. She comes round and has a chat.” Another person described the culture as being treated with respect, “They talk to you and they remember what you’ve talked about and ask you about things later. You’re not just a number. I chose to come here and I haven’t been disappointed.”

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 showed integrity, openness and honesty and had the skills, knowledge and experience to lead effectively. The registered manager maintained a strong presence within the service and actively engaged with people, visitors and staff. Improvements identified at the previous inspection had been addressed promptly, and the registered manager had proactively developed their own knowledge through further training and learning opportunities, which were shared with staff and embedded into practice. For example, they had undertaken additional research and training to strengthen their understanding of supporting people with a learning disability, which helped ensure assessments, care planning and support were more person-centred and reflective of individual needs. The registered manager had also attended conferences relating to safeguarding and regulatory compliance, which improved the wider team’s understanding of recognising, reporting and responding appropriately to safeguarding concerns and statutory notifications.

The leadership team worked collaboratively to support the delivery of safe, effective and good quality care. Staff spoke positively about the registered manager and said they felt listened to and supported. Some staff described receiving compassion and understanding during difficult personal circumstances. A staff member said, “I honestly couldn’t have asked for anything more from them, they were amazing.”

The provider promoted a positive culture where people and staff felt able to speak up and be heard. Staff understood their responsibilities under the whistleblowing policy and said they were confident concerns would be listened to and acted upon. Regular 1:1s and team meetings gave staff opportunities to share concerns and feedback. A staff member said, “I definitely feel I could speak about anything.” Another told us, “The manager, she supports us with our jobs and decisions. She's gives us freedom to speak up” and” She trusts us.” A further staff member said, “They’re a nice bunch of people and good management. If you ever have a problem, you can always speak to someone.”

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 received relevant training to support their knowledge and understanding of equality, inclusivity and fairness in the workplace. Staff uniqueness, diversity, and ethnicity were embraced within the team. Staff told us their individuality was supported by the organisation and were treated fairly. Relevant legislation and best practice guidance was implemented to ensure staff were treated in a fair and equitable manner. Recruitment processes supported fair employment opportunities.

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.

Since the previous inspection, the provider had commissioned an independent third party to undertake quality audits and mock inspections. These processes supported the registered manager to identify strengths, address areas for improvement, and implement targeted action plans with clear timescales for completion. As a result, sustained improvements had been made to the provider’s quality assurance systems.

Quality monitoring and audits were comprehensive and effective in monitoring all aspects of the service. Daily observations and leadership meetings promoted consistent care delivery, while monthly audits reviewed key areas including care planning, medicines management, IPC, and health and safety and staffing. Statutory notifications were submitted to CQC appropriately and in accordance with the provider’s legal responsibilities.

Leaders demonstrated awareness of the operational challenges associated with managing a large 60-bed nursing home. Robust business continuity plans were in place to mitigate risks such as staffing shortages, adverse weather conditions, and IT system failures, helping to ensure the continued safe and effective operation of the service.

The provider understood the importance of partnership working to ensure people received seamless, person-centred care. Information and learning were shared appropriately with partner organisations to support positive outcomes and continuous improvement. People were supported to access routine healthcare and local community facilities, fostering inclusion, and wellbeing.

The service was known and supported within the local community. The service worked collaboratively with local churches and community groups to support people’s spiritual wellbeing, including arranging room visits for people cared for in bed. The provider promoted social inclusion and wellbeing through the celebration of special occasions and significant historical events. Charity fundraising activities and visits from therapy animals were valued and enjoyed by people using the service.

The provider had ensured learning from the previous inspection was used effectively to drive improvement across the service. Since the last inspection, leaders had proactively reviewed practice, strengthened governance processes and introduced new ways of working to improve outcomes for people. These improvements had become embedded into daily practice through ongoing oversight, monitoring and staff engagement, helping to ensure people received safe, effective and responsive care.

There had been positive and sustained changes to service delivery, supported by leaders who promoted continuous learning and improvement. The registered manager actively participated in local and national provider forums and professional networks to remain up to date with best practice and sector developments. Learning and good practice guidance were shared with staff through meetings, supervisions and day-to-day discussions to support ongoing improvement within the service.

Staff told us strong leadership and clear direction had helped them through the disappointment of the last inspection and motivated them to work together to make positive changes. They described an open culture where shared learning, training and reflective discussions helped develop their skills and knowledge. Staff understood their responsibility to be open and transparent if something went wrong and felt supported to learn and improve outcomes. Staff were proud of where they worked and committed to ensuring people received good care and positive experiences.