Sleaford Hall Care 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 service. 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 71 (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 and provider focused on providing people with person-centred care, which reflected their needs and wishes and kept them safe. They ensured staff provided kind, compassionate care that reflected what was important to people and their families. A relative told us, “There is a culture of openness and honesty, and this filters down from the top, making for a happy home, with caring, happy staff.”

The registered manager ensured staff were clear about their responsibilities and the provider’s aim to provide people with good quality, individualised care.

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 registered manager possessed the knowledge and skills necessary to manage the service well and ensure people received person centred care which met their needs and maintained their safety. People and relatives were happy with how the service was being managed.

The registered manager and provider ensured staff completed the induction and training necessary to meet people needs and provide them with compassionate care.

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

People and relatives were encouraged to raise any concerns about the service during regular meetings, reviews and satisfaction surveys. They found the registered manager approachable and helpful and told us they felt able to raise any concerns. No one we spoke with had complained about the service but told us any issues they raised with the registered manager had been resolved quickly.

Staff felt able to raise concerns with the registered manager and felt they would be listened to and acted upon. They were aware of external agencies they could contact, such as the local authority or CQC, if they did not want to raise issues with the registered manager or wanted to escalate them.

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 staff we spoke with were happy working at the service. They told us they felt well supported and could raise any concerns with the registered manager. The service employed some internationally recruited staff, who told us they felt valued and were fairly treated.

Staff were able to raise concerns and make suggestions at regular meetings, during individual and group supervisions and through feedback questionnaires. Records showed that when concerns were raised or areas for improvement identified by staff, the provider took action to address them.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

The registered manager and provider ensured checks and audits of the quality and safety of the service were completed regularly. Many of the audits completed ensured appropriate standards of quality and safety were maintained, such as environmental safety. However, some audits, including those relating to medicines and care documentation, identified repeated issues over a number of weeks or months, without the required improvements being made. This meant the checks were not always effective in ensuring appropriate standards of quality and safety were being maintained.

The provider was aware of these issues and had also identified issues with the accuracy of some of the audits that had been completed. Those audits had recently been repeated, resulting in lower compliance levels which were felt to be more accurate, and action plans were in place to address the shortfalls found.

Staff performance and competence was assessed regularly through observations and supervisions. Records showed that when staff members’ performance fell below the expected standard, the registered manager ensured there was accountability and support was made available.

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.

The registered manager and staff worked well with partner agencies, such as GPs and community nurses, to ensure people received all the support they needed to meet their needs and experience a good quality of life. Records showed referrals were made to a variety of agencies for specialist support when needed.

Where investigations or ongoing treatment took place, the registered manager and staff collaborated with partner agencies to ensure people’s health and wellbeing was monitored, and they were provided with a seamless service. Any learning and updates were shared with partners to improve people’s outcomes.

The provider focused on continuous learning 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.

The registered manager focused on providing people with person-centred care which gave them a good quality of life. They worked well with local partner agencies to meet people’s needs and provide care which resulted in positive outcomes for them. Staff followed advice and guidance provided by partner agencies, to ensure their practice and the care provided was safe and effective.

When accidents or incidents identified shortfalls in processes or practices, improvements were made and lessons learned were shared with staff to improve future care.

The registered manager and provider embraced opportunities to improve and develop the service. They were involved in the local care association, which helped them stay up to date with learning and improvement across their local care system. They received regular updates from CQC, helping them stay up to date with issue relating to regulation and provided feedback to CQC when requested, which contributed to practice and research.