Doulton Court Lodge 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 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 service had a clear and shared direction that staff understood and worked towards. The registered manager promoted a culture that was open, inclusive and focused on person-centred care. Staff described values that reflected dignity, respect, safety and compassion and these were seen in day-to-day practice. The registered manager worked with people, relatives and staff to shape the service and used feedback to guide improvement. Staff felt listened to and said the registered manager led by example. Equality, diversity and human rights were understood and promoted across the service and reasonable adjustments were made to support inclusion. The registered manager monitored risks to achieving goals and took action to address them which helped maintain a positive and improving culture.

The service had capable, compassionate and inclusive leaders who understood the needs of the people they supported and the context in which care was delivered. The registered manager was visible, and approachable. They demonstrated the skills and knowledge needed to manage the service and continued to develop their practice through networking and regulatory updates. Staff and professionals spoke highly of the support and atmosphere created in the service saying it promoted a positive and inclusive environment. One professional said, “The registered manager and staff are highly professional, approachable and always willing to help, creating a supportive and well-organised environment. They are also kind, helpful, and respectful, consistently treating [people] with dignity, patience and compassion.” Leaders promoted an open culture based on honesty and integrity and acted quickly when concerns were raised. Safe recruitment processes were in place for leadership roles and the registered manager understood their responsibilities, including regulatory requirements.

The service fostered an open and supportive culture where staff felt able to speak up and knew their concerns would be taken seriously. Staff said they understood how to raise complaints and felt confident doing so. The registered manager promoted open conversations and encouraged staff to share ideas to improve the service. When concerns were raised the registered manager responded sensitively and took action, and learning was shared with the team. Staff said they felt listened to and supported and that raising concerns did not lead to negative treatment. The registered manager acted with honesty and transparency and this helped prevent closed cultures from developing.

The service promoted equality, diversity and inclusion within the workforce and supported staff to feel valued and treated fairly. The registered manager took steps to ensure all staff had equal opportunities and understood their rights. Staff said they felt respected and that their views were listened to. Reasonable adjustments were made to support flexible working when requested. The registered manager monitored for any signs of bullying, harassment or discrimination and acted quickly when concerns were raised. Training helped staff understand equality and human rights and policies were regularly reviewed to ensure they supported an inclusive workplace. Staff said they felt able to contribute ideas to improve the service and that the registered manager promoted a culture where everyone felt included.

The service had clear systems for governance, management and accountability which supported the delivery of safe and consistent care. The registered manager understood their responsibilities and used audits, checks and feedback to monitor quality and identify improvements. Staff understood their roles and said information was shared in a way that helped them carry out their duties safely. Risks were reviewed and actions were taken without delay when issues were identified. Notifications were submitted to CQC as required and records were stored securely with appropriate data protection measures in place. Business continuity plans were in place and staff understood what to do in an emergency.

Feedback from external professionals about the management of the service was positive. One professional told us, “There are no concerns with the home or the management of the home. There are good audits in place and [person] led approaches being implemented. The management are very responsive with any concerns, or any actions that have needed to be completed in the past.”

The registered manager used information about performance to plan improvements and ensure sustainability. Systems for workforce planning helped them monitor staffing needs and maintain stability. They engaged people in discussions about the service and used this feedback to inform decisions. One person said, “[The registered manager] and the staff have turned the place around. It was ok before but now it is a place called home.”

The service worked in partnership with people, relatives and external organisations to support joined up care. Staff understood when to involve other professionals and made timely referrals which helped maintain continuity. The registered manager was open and transparent with partners and shared information that supported improvement. One professional said, “My experience working alongside the team has been consistently positive, and I feel confident that [people] benefit from the culture and leadership within the home.” The service was part of the local community and worked with local groups to support people to stay connected. Staff supported people to attend community activities which helped improve wellbeing. The registered manager engaged with external networks to share learning and identify new ways to improve outcomes such as charities who helped people understand their rights. Communication with partners was effective and guidance from external agencies was included in care plans to keep support aligned and coordinated.

The service supported continuous learning and improvement and the registered manager encouraged staff to share ideas to enhance the quality of care. Staff were involved in reviews of incidents and understood how learning was used to make changes. The registered manager welcomed feedback, including when it was critical, and acted on it. People and relatives were involved in discussions about improvements and were asked for their views. Audits and checks were used to monitor quality and measure the impact of changes. Staff were encouraged to develop their skills and contribute to innovation. The registered manager engaged with external partners to share learning and consider new approaches that could improve outcomes. Systems were in place to ensure learning was captured when things went wrong and good practice was recognised.