Mickleboro 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 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 had a shared vision, values and strategy which was promoted consistently with staff starting from interview and continued through their induction, training, supervision and team meetings. Staff understood these values and how they threaded through their roles to provide safe, high quality and compassionate care to people using the service. Comments included, “The values guide me on how I present myself at work and the support I give the people, and ensures I am responsible for my actions,” and “DS Healthcare are going to big; they want to expand they will be here in the future. They are respectful, and big on promoting equality and diversity.”

The provider had a positive, compassionate and listening culture that promoted trust and understanding between the leaders, staff and people using the service. This was demonstrated consistently through records of meetings and observed interactions between staff and people. The service had a charter of rights for people using the service which promoted equality, diversity and their human rights. Staff had a good understanding of people’s rights and actively promoted these to ensure they were respected and treated fairly.

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 provider and leaders demonstrated they had the experience, capacity, capability and integrity to ensure the organisational vision was delivered and risks were well managed. We observed the provider and leaders at every level were visible and led by example, modelling inclusive behaviours. From our discussions with the provider, it was clear they had the knowledge and credibility to lead effectively. Staff told us since DS Healthcare Ltd had taken over the service had improved a lot. One member of staff commented, “Since taking over the service, a lot has improved, the house has changed. Previously it was dirty, and there was a lack of staff and food. Now we have more staff and people have a budget to buy their own food.”

Systems had been developed to ensure staff were provided with regular support and guidance to enable them to effectively carry out their role. This was confirmed in conversation with staff. One member of staff commented, “We have good help from management and staff are working as a team.” Poor staff performance which had the potential to impact on the quality of the care people received or have a detrimental impact on other staff was addressed quickly.

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

Staff and leaders acted with openness, honesty and transparency. Staff told us there was a culture of speaking up where staff were able to raise concerns, and they were supported without fear of detriment. Comments included, “I am aware of rights in this country which give people the ‘freedom of speech and right to voice their opinion’. I do feel able to raise concerns with the provider,” and “We covered freedom to speak up in my induction, if I see something that is wrong, I will write to management, or I can take it further to CQC or safeguarding.” Complaints, audits and supervision records showed when concerns were raised, the provider and leaders investigated these sensitively and confidentially, and lessons learned were shared and acted on.

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.

Systems were in place to continually review and improve the culture of the service. The provider told us, “We have a diverse workforce from the directors down and equality, diversity and inclusion are the root of our mission statement.” The provider continually reviewed the culture of the organisation in the context of equality, diversity and inclusion. For example, they had noted on the rota that weekend shifts were either predominantly worked by staff from an ethnic minority or by white staff. In viewing this as a barrier they ensured the weekend workforce was diverse.

The provider created an environment to embrace and understand different cultures through transparency and communication to enable staff to share their perspectives and differences. They had recently worked with Norfolk County Council who provided training to staff about bullying and racism in the workplace. The impact of this had helped address differences and clashes of personality amongst staff.

Interview processes demonstrated good exploration of what a potential new staff member could bring to the role, their values, how they communicated with people, different methods of communication, their understanding of mental health needs and equality and diversity. Records showed any causes of any workforce inequality was identified and action taken to address these. Staff whose first language was not English had support with English language and the staff handbook, assessments, policies and procedures were adapted where needed into simpler versions to aid understanding. The provider had a robust equality and diversity policy in place which included procedures for managing the protected equality characteristics of staff. For example, in accordance with the policy the provider had made reasonable adjustments to support a member of staff to carry out their role throughout their pregnancy, including flexible working arrangements.

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.

The provider had robust and effective governance systems in place to proactively and continually assess the quality and safety of the service, drive improvement or find where lapses had occurred. Multiple audits had been implemented and used to manage quality, performance and safety of service. The results of audits fed into an improvement action plan which was monitored and reviewed by the quality assurance team. This information was used effectively to check and improve the quality of care. Robust arrangements for the availability, integrity and confidentiality of data, records, and data management systems. Notifications were consistently submitted to external organisations as required such as local authority and CQC, including notifiable safety incidents and safeguarding concerns.

Clear and effective governance, management and accountability arrangements were in place to ensure the quality and safety of the service. Staff told us under the new provider the service was more organised and managed better. One member of staff told us, “The provider has good oversight of the service, there are a lot more audits in place, and outcomes are shared with us. The provider is here a lot, and the team co-ordinator who provide support.” Records of staff supervision, Let’s talk about it, grievance and performance showed the provider could account for actions, behaviours and performance of staff.

The provider had a pro-active approach to learning and development to prioritise staff training and develop a confident and competent workforce, ultimately improving the lives of people using the service. Staff told us, they had received more training and were better supported by the provider. One member of staff commented, “We have achieved a lot of training. Training used to all be online now we have in person training. Staff have regular supervision now, I supervise staff, and the provider ot team coordinator supervises me.”

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 collaborated with all relevant stakeholders and agencies and maintained close contact with CQC, the local authority, integrated care board (ICB), mental health services and social workers. We received positive feedback from partners, that the service was open, transparent and responsive. The provider had formed a good working relationship with CQC through transition from the previous provider. They voluntarily sent weekly updates to CQC on how they were meeting their improvement plan, ensuring their organisational vision was being implemented, how the service was developing, how they were managing risk and improving outcomes for people.

The provider and staff worked in partnership with key organisations to support care provision, service development and joined up care, including the GP, mental health services, NHS mental health clinics, social workers and community nurses. We received positive feedback from partners, that the service was open, transparent and responsive.

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.

The provider was focused on continued learning and improvement. They had implemented an ongoing development plan to drive improvement. The provider, leaders and staff had a good understanding of how to make improvement happen. The approach was consistent and included measuring outcomes and how they impacted on people and staff. The provider ensured people, their families and staff were involved in developing and evaluating improvement. They encouraged creative ways of delivering equality of access, experience, outcome, and quality of life for people.

The provider and management had robust systems to ensure learning happened when things went wrong. There was a record of actions and lessons learned taken forward from events. This included, debrief sessions for staff to reflect and learn from things have gone wrong. Staff were supported to develop their skills and capabilities around improvement and encouraged to contribute to improvement initiatives. One member of staff commented, “We, old and new staff all work together to improve the service, we love our jobs, try our best to support each other and the people using the service.”