Legh House Also known as Abbeyfield Legh House

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 newly registered 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 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 provider and registered manager showed the skills and experience needed to lead the service effectively. They maintained a clear focus on priorities and demonstrated a transparent, open approach throughout the assessment. Any minor areas for improvement identified were addressed promptly and in a responsive manner.
Staff told us they worked well together as a team and contributed to a kind and supportive culture within the service. They felt confident raising ideas or suggestions and said these would be listened to. Staff also described the management’s open-door approach to leadership, which made them feel supported and able to discuss any concerns.
Staff developed strong relationships with the people they supported, and effective communication within the team helped them provide consistent and person-centred support.
 

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 was experienced and had a good understanding of their role, responsibilities, and the relevant legal requirements, and worked proactively to ensure compliance. People and relatives told us the whole management team was approachable. A relative commented, “The management has been excellent.”

Staff told us they felt supported by the management team and there were opportunities to share information to ensure people received care safely, this included regular staff meetings and daily handover meetings. The leadership were very involved in the day to day running of the home and were passionate about the service.
 

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

The service had a whistle blowing policy and a dedicated phone number displayed in the service for staff to raise any concerns. Staff had been reminded of their responsibilities to report concerns in a recent team meeting. They were given regular opportunities to raise concerns and provide their feedback.

Staff we spoke with told us they were confident to raise concerns with the manager and that they would be listened to. One staff member told us, “If something happened, I would tell the manager, any abuse I need to report and raise it.”
 

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 service employed a diverse workforce. Mandatory equality and diversity training was in place for all staff, with refresher training to maintain awareness of protected characteristics and discrimination.
Staff had the opportunity to discuss their wellbeing, job satisfaction, and any support they required within their supervisions. Any assistance staff required to support them to manage their work life balance and health conditions was discussed as part of the recruitment process and then at regular intervals. Any reasonable adjustments staff required had been implemented.
 

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.

Services we regulate have a statutory responsibility to notify CQC about certain events that occur in a service. Notifications were submitted, as required.

Auditing processes were in place to monitor the service. Daily observations were used to maintain consistency of care, while monthly and quarterly audits covered key areas such as care plans, medicines management, infection prevention, and health and safety. Findings were recorded and followed up on, ensuring any shortfalls were addressed promptly and effectively.
 

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 provider was transparent, collaborative, and open with all relevant external stakeholders and agencies. Staff worked in partnership with key organisations to support care provision, service development, and joined-up care to improve people's experiences, health, and wellbeing. The provider established effective processes to ensure partnership working with people, relatives and health professionals was maintained.

We received positive feedback about working in partnership from all health and social care professionals who responded to our request. Comments from partners included, “It’s a pleasure to work with this service. Management always works well with myself and my team and is as flexible as can be whilst always considering the safety of all the service users and staff.” And “I have no complaints at all and can only sing their praises.”
 

The provider 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 contributed to safe, effective practice and research.

People and relatives told us they were consulted individually during a review or regular conversation, to find out if they had any concerns or requests. We saw people’s opinions and requests were taken seriously.
Quality assurance arrangements were in place to help identify any areas for improvement. Leaders considered information about the service’s performance and how it could be used to make the required improvements. Lessons were learned following incidents and safeguarding concerns to help support improvements in practice.
Staff told us leaders were always aiming to make improvements to the service to benefit people, and they enjoyed being part of this. The registered manager was committed to developing the service to benefit people and the staff team.