Lonsdale Mews

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 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.

Whilst staff were unable to quote the specific wording of the service’s visions and values, all staff were able to communicate the overall values of the service and were united in the aim to deliver good quality, safe care.

We observed staff to deliver care and communicate with people in a supportive and compassionate way, and people responded well to staff approach.

The registered manager told us the key words from the organisation’s values were caring, teamwork and passionate. The registered manager explained their staff interview questions were focused on these key words to ensure they were only recruiting staff who genuinely believed this was how care should be delivered to people.

Staff told us they worked well together as a team, and all helped each other out when needed.

There was a focus on learning and improvement across the service, and the provider ensured all staff had access to policies such as the equality policy.

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 leadership team were passionate and dedicated to delivering good quality care to everyone who lived at Lonsdale Mews. Leaders were visible, present, and engaged.

Staff feedback about leaders was positive and reflecting that they could ask for support with personal matters as well as work matters. A staff member said, “If anything happened at home and I was upset, [acting home manager] would support me.”

Staff were confident in the knowledge of leaders and frequently cited seeking their expertise when they were unsure about a problem.

The current registered manager had been promoted, and the deputy manager had stepped up to become acting home manager. However, the registered manager retained oversight of the service and visited regularly. They also had access to the digital care planning system to ensure they could maintain oversight of operations when they were not onsite.

Audits and visits were completed by the regional manager, to ensure consistency across the organisation.

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

Staff told us they felt confident in speaking up if there was an issue or a concern. Staff regularly attended team meetings to share ideas and raise issues or concerns they had identified.

Across the organisation, a new confidential reporting telephone line had been implemented and had been used by other homes elsewhere in the country. The registered manager spoke positively about this and felt this was a very good idea to ensure all concerns could be captured, even in sensitive situations such as where staff had an issue with someone in the leadership team who would normally be the person concerns were escalated to.

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 provider valued staff from a range of backgrounds and supported them to stay well at work. One staff member found their rota was not suiting them, and the provider had worked with them to devise a rota which met their needs. Staff who had dyslexia were supported with adjustments to help them complete their role. One staff member said, “[Registered manager] and [acting home manager] are brilliant, they are supportive. I have [caring responsibilities outside work], anytime I’ve needed to go, or needed help, they have been straight there.”

Staff told us they were treated fairly and equitably and had access to a range of wellbeing tools such the employee assistance programme, and the opportunity to purchase additional annual leave days.

The provider mostly 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.

Whilst the majority of the provider’s systems and processes were robust and effective, there were a couple of processes which required reviewing by the registered manager, such as the application of creams to people living at the service, and to ensure all care plans were updated as a whole, rather than in silo, to ensure information was consistent throughout.

We identified some areas of the service had not been recorded as being cleaned as per the cleaning schedule, due to staff leave and absence. The contingency plan for this required review.

Audits were regularly completed by the leadership team, however, some of these required some adjustment to ensure the issues identified at this assessment could be captured and actioned efficiently.

Statutory notifications, which is a notification care providers must submit to the Care Quality Commission in the event of an accident, serious injury or untoward event, had been submitted where applicable.

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 had worked to build links with local organisations to strengthen their community involvement.

A local dance teacher came in to facilitate intergenerational dance sessions, some students from the local secondary school had completed work experience at the service, and a couple of young people had been supported to undertake their Duke of Edinburgh award at the service.

The service was currently working to raise money for a charity which supported people experiencing homelessness.

The service had completed their accreditation with the Gold Standards Framework and the Veterans Friendly Framework, to support people who had served in the Armed Forces.

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 had systems and processes in place to learn when things went wrong. The registered manager and staff team had worked hard since the last assessment to make the required improvements and embed them into daily practice.

Lessons were shared amongst other homes within the organisation, such as where a choking incident had occurred at another service, and a person had gone missing at another. This was to help prevent further occurrences at other homes, such as Lonsdale Mews.

We saw evidence of learning and development being shared within team meetings. The team leaders regularly attended morning briefings and the minutes of these recorded lessons being shared, such as information about the choking incident at another service. Staff told us they were informed of any changes, developments within the service and were offered opportunities to share their thoughts and feelings openly.