Norton Lees Hall & 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 of this key question under the new provider. This key question has been Requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The previous management team did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. Staff did not consistently work towards a shared direction or vision for the service. The provider had recently implemented changes to the management team who were working with staff to foster a more positive culture, and to support staff in delivering consistent, high-quality care. The current management team had developed an action plan and had commenced implementing changes. They understood the work required to embed these improvements and ensure they resulted in sustained and positive outcomes for people.

The previous management team did not understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation and did not always have the skills, knowledge, experience and credibility to lead effectively. However, recent changes in the management team had resulted in shortfalls being identified and acknowledgement that notable improvements were required. We found the new management team demonstrated the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty. The team were very new in post and required time to implement changes, so they would be fully embedded and sustained.

People did not always feel they could speak up and that their voice would be heard. Although the current management team had taken steps to encourage a more open and transparent culture, these were still in the early stages and needed to be consistently embedded in the service.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Recent changes in the management team were having positive changes to improve equality, however, further work was required to ensure diversity and inclusion were consistently promoted and reflected in everyday practice.

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, or share this securely with others when appropriate. The new management team had begun strengthening governance processes to improve oversight of the service. The new management team had identified areas for improvement and had developed a robust action/improvement plan to start addressing concerns within the service. The plan was continually monitored and reviewed to ensure progress by the provider, however, was not fully aware of staff concerns and following feedback we received from staff regarding staffing levels, the provider agreed to look into this and sent us confirmation of action taken to ensure people’s safety.

Positive improvements had been taking place and these were encouraging. However, more time was needed to implement and embed these across the service. The provider clearly understood what was required to embed the practices, change the culture and empower the staff to drive improvements.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They continued to share information with partners and collaborated for improvement. The staff team worked closely with health and care partners, and they followed advice and guidance to ensure good outcomes for people.

The current management team had started to embed a culture of continuous learning, innovation and improvement across the organisation and local system. They were encouraging creative ways of delivering equality of experience, outcome and quality of life for people. The provider was making changes to improve the service based on feedback received from staff, people and relatives. The new management team demonstrated a commitment to improving people’s experiences, outcomes and quality of life by encouraging new ways of working and promoting reflective practice. These initiatives were still in their infancy and required time to fully embed so sustained improvements in the service could be demonstrated. One relative said, “I do feel the new manager is listening, and wanting to resolve issues.”