Lea Court

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

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.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At our last inspection we rated well-led as requires improvement. At this inspection, the rating has been changed to good. Leaders had the skills, knowledge, and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported, and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance. They used this to identify improvements.

The service had been in breach of regulation 17: Good Governance because they had not ensured that governance processes were completed and managed in line with the provider’s and management’s expectations. They had not ensured that all environmental and daily checks were completed and recorded appropriately; or that any issues identified through audits or reviews were escalated and actions taken. At this inspection we found that improvements had been made. Governance processes followed the policies in place, and staff undertook audits to ensure daily checks were being carried out effectively. Audits and reports regarding environmental risk assessments, such as Legionella and water temperature checks were carried out and fully reported on and monitored. A full calendar spreadsheet outlining audit responsibilities for each level of staff member at the service was comprehensive and followed by the service.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We scored the service as 3. The evidence showed a good standard. The service 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.

• Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. We noted that the visions and values of the organisation were on noticeboards and placed around the service. Staff we spoke with were able to talk about the visions and values and the need to understand and implement them to ensure patient service was optimal. The service had a folder dedicated to the regulations of the Health and Social Care Act 2008 that staff could access and which outlined the importance of implementation.
• The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. The provider senior leadership team had a “uMatter Walkabout Briefing Document” that recorded visits by senior management to the service and their findings. Designed as a fundamental part of the provider governance framework, we saw that the contents of this document for the service considered all aspects of the service and its work with patients and staff. Any actions were noted and discussed with relevant staff and were signed off on the document when completed.
• Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. The provider had an internet access page staff that included “uMatter Employee Voice” and “uMatter Growth and development” as standard applications. They allowed engagement with services, equality information access, a feedback forum “Every Person Matters”, and career pathway and development sites. Staff survey results showed that there was a lot of positive progress within the service, with staff commenting favourably on the workplace and team being a good place to work
• Staff could explain how they were working to deliver high quality care within the budgets available. A new electronic notes system that would help improve care planning was being introduced. They were currently using the older paper-driven system, but training was ongoing in improving the standards of care planning at the service. Staff said their training indicated that the updated system would be more effective and save time at the service.

We scored the service as 3. The evidence showed a good standard. The service 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.

• Leaders had the skills, knowledge and experience to perform their roles. The registered manager told us that all staff had empowerment training and had five set face to face management days at the service. The registered manager was a very experienced practitioner, and staff told us that this was reflected in the understanding and approach of the manager towards agreed supporting of staff and patients.
• Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. The registered manager of the service showed a comprehensive knowledge of the service and was able to identify improvements made since they joined the service in January 2025. These improvements had led to the service being nominated for four separate provider awards and were given the award of frontline mental health team of the year for 2025. Patients we spoke with told us of the improvement of the service, and their satisfaction with how their needs were being met.
• Leaders were visible in the service and approachable for patients and staff. We reviewed reports from senior leadership that outlined findings from visits and the actions taken to improve any shortcomings. Patients told us that staff were always approachable, and an employee of the month poster showed what patients thought of the staff that cared for them, with no negative comments given. Staff told us that the registered manager always had an open door, and any matters of concern or even minor issues could be discussed and a way forward found.
• Leadership development opportunities were available, including opportunities for staff. One staff member was a health care assistant who had been supported in a nursing apprenticeship and was in the second year of their degree. They described how the staff team worked together to support them to fulfil their daily role alongside time to complete their studies and work-based assignments. and working with the different professionals within the service.
• Staff reported high regard for managers who showed them empathy and stated they felt fulfilled at work. The survey also identified areas for improvement regarding pay and staff leave policies.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

• Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The service gave us access to two recordings of patient independence journeys relating to patients who, until recently, struggled with their mental health and maintaining improvements. The recordings, made with the assistance of the patients and carers, showed how their time at the service had improved their lives and how they were thriving in the community. Patients we spoke with and who approached us independently whilst touring the service stated that there had been improvements since the new registered manager had arrived. We reviewed patient community meeting minutes, 3 sets from the 6 months prior to the inspection and saw that a standing agenda item referred to the “Transformation of Lea Court” and had items of interest that related to patient care and improvements to the service. Patients had the option to comment on these and to ask questions across the agenda items. Some points raised in these meetings were put into the agenda for patient multi-disciplinary meetings, especially if a patient made requests that were personal to them. The service provided a mental health recovery cafe where patients and staff were able to discuss matters in an informal way.
• Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Information submitted by carers or patients was reviewed and matters raised dealt with within the governance framework. Staff meeting minutes had a standing agenda item for lessons learned, which could be used to inform staff of incidents or comments from carers and patients that required consideration. Staff told us that they felt their voice was heard by management, especially since the arrival of the new registered manager.
• Patients and carers were involved in decision-making about changes to the service. The service had a newsletter for patients and staff, ‘Lea Court news’, presented in a newspaper format, outlining the events of the week and how patient involvement had improved the service. We saw three newsletters, these had photographs of patients joining in with events, news about a recent visit to the service by the local member of parliament, and comments from patients and staff that raised positive points of view. During the inspection, we met a former patient who was in the lounge of the service, the patient visited the service 2 or 3 times a week, sitting with patients and having refreshments. This was encouraged by the registered manager and the team, as there was a positive impact on the patients and allowed staff to ensure that any problems the former patient might raise could be dealt with without involving a possible readmission to the service. The patient was deemed appropriate by the registered manager, and the level of risk was minimal.
• Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback. The feedback report from the senior management walkabout showed that they had close interaction with patients and took their opinions and views on board. Patients approached them and told them only positive aspects about the service, without prompting. Senior management were impressed that the atmosphere allowed for staff and patients to feel comfortable with visitors, even though the visit was unannounced. This approach was reflected during the inspection of the service, patients were happy to put their opinions to the inspection team and told the team they were able to raise concerns.
• A report by the Quality Network for Mental Health Rehabilitation Services’ Peer Review Process team found that staff were listened to by management, and that the registered manager was deemed very approachable by staff and patients. This process brings together clinicians, service users, and carers to evaluate rehabilitation wards against evidence-based standards, fostering an open culture of learning, sharing best practices, and improving quality of care.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

• The service had equality and diversity champions and an equality and diversity lead. Staff told us that they could approach the equality and diversity lead for information and discussion, or any other staff member if they wanted to discuss such matters.
• Staff were able to apply to work flexibly; there were flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. Several staff members had been granted the opportunity to work condensed hours, giving an extra day of leave in the week.
• Managers put reasonable adjustments in place for staff members to help them carry out their role. Family friendly considerations, as well as reasonable adjustments were available to staff members, and the governance policy allowed for such considerations. Staff we spoke with had reasonable adjustments in place.
• The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. The provider had an Equality Diversity and Inclusion (EDI) Analysis report that was provided. This showed breakdowns of staffing by gender identity, age, nationality, disability, and other characteristics. It indicated that the workforce was representative. Staff were given the option to not indicate their characteristics, and this was also reflected. The document was anonymised.

We scored the service as 3. The evidence showed a good standard. The service 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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

• There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. We reviewed care records and saw that they were comprehensive for multi-disciplinary meetings, as well as staff meeting notes itemised with standard agendas that included lessons learnt and complaint consideration.
• Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service. The provider had a policy regarding individual rights that outlined the process and timeframes for the handling of information requests provided. In staff meeting minutes, we saw that the service had identified several incidents where patients had gone on leave but failed to return within the timeframe allowed, resulting in action plans for patients that met the least restrictive practice policy of the service. Each patient had a restrictive intervention care plan.
• Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. The service had a detailed audit calendar that was in spreadsheet format, outlining the audits that were required by each level of staff from registered manager to support staff. It clearly outlined the monthly and weekly audits that were required to be carried out. We reviewed care file audits that were submitted by the service, these were in a spreadsheet format and related to each patient and the individual care plans and files for each patient. These included care plans for physical health, mental health, social inclusion, discharge planning and section 17 (leave) planning.
• Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. Staff we spoke with were aware of the need for collaborative working within and outside of the service. The service maintained a file for any dealings with the Care Quality Commission (CQC), containing relevant copies of correspondence and information shared.
• Management of risk, issues and performance were covered by audits, a risk register and ensuring that key performance indicators were monitored and any arising actions dealt with. Staff maintained and had access to the risk register at ward as well as directorate level. Staff at ward level could escalate concerns when required. We saw the risk register for the service and for the provider, both were up to date and comprehensive. Staff could add items to the register but often left it to senior managers after informing them of concerns. The service risk register had only 4 items, including local flood risks and actions to take and smoking in bedrooms by patients.
• Staff concerns matched those on the risk register. Staff told us that they did not consider the service to be a high-risk service and felt that they could cope with any problems that might arise in their working hours.
• The service had plans for emergencies – for example, adverse weather or a flu outbreak. Respiratory illnesses were covered in the service risk register, as was the risk of flooding (the area surrounding the service has a history of flooding in heavy rain).
• Where cost improvements were taking place, the registered manager told us it did not compromise patient care.
• The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff. Staff told us that the systems were user friendly.
• Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. Laptops, work phones were available, limited paper copies of documents were used such as appointment letters for patients.
• Information governance systems included confidentiality of patient records. Any paper documents were secured, and a new electronic notes system was being introduced.
• Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.
• Information was in an accessible format, and was timely, accurate and identified areas for improvement.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

• The provider worked closely and in conjunction with many councils and NHS services across the North-West of England. The provider worked with over 50 housing partners to ensure supported patients had access to good quality housing in the community. We received no negative feedback from commissioners regarding the service. The provider worked closely with both local authority and NHS commissioners.
• The advocacy service for the location was commissioned by the local borough council and told us that they had a good working relationship with staff at the service. All patients who needed independent advocacy were referred, and advocates attended the service weekly, as well as when requested for multi-disciplinary reviews or meetings.

We scored the service as 3. The evidence showed a good standard. The service 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 contribute to safe, effective practice and research.

• In July 2025 the service was signed up to the Quality Network for Mental Health Rehabilitation Services’ Peer Review Process, which is a quality improvement process run by the Rehab Network. This was part of the Royal College of Psychiatrists. A full self-review of the service was carried out, along with a visit from a peer review team who looked closely at the service, and an 82-page report was issued, which also recognised the last inspection report from the CQC. The report included patient and carer views, as well as staff views, and showed a positive outcome for the service. The peer review team findings broadly matched the self-review declarations of the service.
• The registered manager had introduced incident reviews that included input on restrictive practice reduction, trauma informed care, and emphasis on lessons learned. There was also a CQC Tracker that monitored and categorised statutory notifications submitted by the service and used a graph to indicate patterns. A staff survey of open-ended questions designed to seek improvement ideas was conducted by the registered manager, with a 77% staff response rate. The responses were positive, one question asking staff for improvement ideas, and the response was formulated into an on-going action plan based on staff suggestions.
• The service was participating in AIMS (Accreditation for Inpatient Mental Health Services) rehabilitation accreditation, with a second inspection due at the service in June 2026.
• A nurse at the service was part of a parliamentary internship for a NIHR (National Institute for Health and Care research) development programme.