Henley 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. This is the first assessment for this service since its registration. This key question has been rated good. This meant the service had adequate management oversight. Leaders and the culture they created promoted safe, effective and person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People received care and support from a staff team that was trained, supported by their leaders and guided by appropriate processes and policies. This created a positive culture and an environment where risks were minimised.

Leaders supported staff by setting clear expectations and encouraging regular discussions around best practice. Recent staff meeting minutes showed conversations were held on different topics, including respecting people, record keeping, safety and escalating concerns. This indicated staff and leaders were constantly looking for ways to improve people’s care.

Staff also engaged with people through regular ‘residents’ meetings in which people had the opportunity to provide their views on their care and the service.

Leaders had the skills, knowledge, experience and credibility to lead effectively. They worked as a team and addressed poor practice that could affect the quality of people’s care.

Although the registered manager was not permanently based at the service, they visited regularly and made sure they were available when needed. They demonstrated knowledge and an understanding of people’s needs and the type of service they managed. A staff member told us, “The team leader and registered manager are really supportive. The registered manager is available even on weekends, they will always answer your call and are always ready to help.”

We observed a senior staff member leading and supporting the staff team confidently, while also attending to people’s needs effectively.

The service fostered a positive culture where staff felt they could speak up and their voice would be heard. Leaders encouraged staff to raise concerns promptly and this was evidenced in staff meeting minutes. Instructions to staff included, “Do not wait for things to escalate to let leadership know, pick up the phone and call someone immediately.”

Comments from staff included, “They always ask for my opinion in meetings” and “I can speak up comfortably, I feel listened to.” This empowered staff to drive improvements.

The service 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 leaders were helpful and would try to accommodate their needs, such as their work shifts. This promoted their wellbeing and helped them perform to the best of their abilities.

The service implemented systems and processes to monitor the quality of service and ensure care was delivered smoothly. Leaders carried out regular audits in areas such as health and safety, care planning, mealtimes and medicines.

However, staff/leaders completed some of the audits in a generic manner and records revealed the relevant areas audited were not always thoroughly assessed. For example, mealtimes audits did not record any feedback from people, items on the menu that day, any observations about how people presented nor information about staff who were present. This lack of detail meant there was a risk the quality of service was not being monitored in a way that fully enhanced people’s experiences while addressing issues effectively. We raised this concern with leaders following the inspection visit.

There was a clear staffing and management structure where each staff understood their roles and responsibilities. Leaders understood their regulatory requirements and maintained adequate oversight of the service. Staff made sure confidential information was stored safely and in line with data protection principles.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and worked together with partners to improve the quality of care for people. We found clear records of interactions between the service and other agencies.

The service focused on continuous learning and improvement. Leaders gathered and analysed feedback from people, visitors, professionals and staff, and used this information to improve the service. Staff captured people’s feedback in a ‘you said, we did’ format. This demonstrated suggestions made by people and how the service implemented them.

Leaders encouraged staff to speak up and share ideas. They oversaw processes that ensured learning took place when things went wrong. They also shared learning, examples of good practice and any useful tips with other services under the same provider. This approach helped the services provide better care and support to people.