The Lawns

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

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.

People and their relatives told us there was a positive culture and atmosphere at the service. They described the atmosphere as “welcoming”, “relaxed” and “homely”. One person said, “I am very comfortable here. The staff are nice and they know me very well.” Relatives commented, “The home is brilliant. I couldn’t fault them. It is very friendly” and “I would definitely recommend this home.”

The provider had core values which were shared with staff at their interview, induction and were available at the service. The provider also had their values available on their website. The registered manager said they carried out ‘manager walkabouts’ which helped them spend time with people and relatives every day.

Staff demonstrated an understanding of the provider’s values in their day-to-day interactions. Relationships between staff and people were respectful, and there was evidence that people were treated with dignity and kindness. Systems were in place to support openness, including opportunities for staff to raise concerns, share feedback and contribute to service development. Staff understood the vision for the service and the importance of transparency.

Leaders promoted a culture of continuous improvement, using feedback from people, relatives and staff alongside governance information to inform changes. Engagement with external professionals and the wider community also supported an inclusive approach.

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.

The service had a registered manager who had joined the service since the last assessment. They were supported by a deputy manager and senior staff. There was a clear line management structure which staff understood. Leaders were supported with regular visits from the area manager and other central office staff.

The registered manager demonstrated an in-depth understanding of all areas of the service, including people’s needs and any challenges. They effectively acted on areas of improvement that were highlighted by our last assessment and by actively seeking feedback and identifying areas requiring further development. There was a focus on promoting a positive culture in the service and our observations confirmed this as staff demonstrated the provider’s values in their interactions with people.

People and their relatives told us they knew who the registered manager was and that the service was managed by capable, transparent and compassionate leaders. They described the registered manager as “visible” and “approachable.” One person told us, “[Registered manager’s name] is good. Without [them] things don't happen.” Comments from relatives included, “The new management have turned the place around from what we read of the previous report. The manager is lovely” and “I know who the manager is and if I had any worries I know I can speak with them or other staff.”

We received mixed feedback from staff about the management team. Not all staff felt supported and listened to. Comments included, “I am not happy with the management, no support, no compassion and empathy towards [their] staff” and “[The registered manager’s name] tries to be supportive. [They] said that [they] had inherited a culture where staff were so used to their own way of working, they had fallen into bad practices and [the registered manager] is determined to turn the home around. I admire this, but the downside is that [name] does not seem to listen to the team.”

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

There was evidence of an open and approachable culture, where staff, people and relatives felt confident raising concerns or sharing feedback. There was information on whistleblowing and safeguarding available around the service and in staff rest rooms. Staff knew how to speak up and raise concerns and told us they would feel comfortable doing this. People and relatives knew what to do if they needed to make a complaint and were assured concerns would be investigated and taken seriously. The management team kept a record of concerns and made sure people were responded to with a resolution and any changes that would be made as a result of the concern being raised. One person told us, “I would tell them straight away if I was unhappy with something. Staff would listen. I could tell [the registered manager’s name] who is a very nice [person].” Relatives agreed, “I know who the manager is and if I had any worries I know I can speak with them or other staff.”

Staff demonstrated an understanding of their responsibility to report issues, including safeguarding concerns and incidents, and there were clear systems in place to support escalation and response.

People and relatives were encouraged to share their views through multiple feedback channels, including day-to-day conversations and resident meetings. Where concerns were raised, these were addressed promptly and appropriately, with feedback indicating that people felt listened to and informed of outcomes. Learning from concerns and incidents was shared across the team, contributing to improvements in practice and reinforcing openness.
 

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 had policies and procedures supporting diversity and inclusion within the service and promoted diversity and inclusion in the workforce. Staff were from diverse backgrounds, and everyone was welcomed into the service. Staff and leaders demonstrated a good understanding of the Equality Act. Staff told us they would care for anyone if they needed it, regardless of their background. Staff had completed equality and diversity training, and they understood their responsibilities towards people and colleagues. Staff were able to recognise discrimination and bullying and knew how to report this. Leaders took action to prevent and address bullying and harassment at all levels and for all staff, including those with protected characteristics.

The provider valued diversity in their workforce. Leaders supported work towards an inclusive and fair culture. For example, by improving equality and equity in the team and ensuring equality of opportunity and experience for the workforce, throughout their employment.

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.

The provider completed various audits, including in relation to nutrition and hydration, incidents and accidents and health and safety. Additionally, senior staff undertook spot checks and observations of staff. There was a ‘resident of the day’ process which included a monthly review of all care plans and risk assessments. Audits and governance measures put in place by the registered manager and the management team had proven to be largely effective in identifying and addressing areas where improvements could be made. However, further improvements were needed to strengthen oversight of medicines management. Monthly medicines audit completed by the registered manager was not always effective and did not identify shortfalls found at this assessment. The provider took immediate action and implemented additional more in depth and focused audits of the medicines.

Where the provider identified areas of improvement, they had set timescales of completion and addressed these. We found the registered manager was motivated to make the improvements we identified during our assessment.

The management team was established and were continuing to work on improvements and strengthening their oversight of care quality and safety. Leadership was multi-layered and various audits and checks meant care provision was continually improving. Legal requirements, including about conditions of registration and managers, were understood and met.

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.

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