Archived: Tollington Lodge Rest 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. The provider’s governance systems were not always efficient in ensuring information and records were accurate. The service was in breach of the legal registration regulation in relation to the notification of other incidents.

This service scored 62 (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 registered manager told us they promoted the service values through the recruitment process and in staff supervision.

Staff were able to get to know people they supported well and communication between their team assisted them in providing effective support to people.

Senior staff held staff meetings regularly. Staff could raise ideas or suggestions and would be listened to. One staff member told us meetings were an opportunity to ‘talk through issues or positive things going on’.

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 told us they were supported to undertake their role well. They had access to regular support from the provider and attended quarterly registered manager forums.

Staff felt well supported by the registered manager and deputy manager and were complimentary of the level of support they received. A staff member said, “The management are amazing and are always there to support all the staff.”

People and relatives told us leaders were approachable, and they could speak to them when they wished to. One person told us, “I can talk to the staff, they come in for a chat and I know the manager and can chat to them.”

A professional told us, “The registered manager presents as passionate and dedicated to providing excellent standards of care."

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager promoted a culture of being open and honest.

Staff were asked if they had any areas of concern they wished to raise during their supervisions.

Staff told us they were encouraged to speak up if they had any concerns and would feel comfortable to do so. Comments included “We work as a close team so if we did have concerns, we can talk them through” and “I know if I needed to talk to the managers I could, and they would always respond."

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.

Formal feedback in the form of questionnaires had not been requested from staff. However, the provider had systems to support staff, and staff had access to an employee assistance scheme. Staff had the opportunity to discuss their welfare, job satisfaction and any support they required within their supervisions. Staff told us about various examples of how they had been supported when they had requested flexibility in their working arrangements.

One staff member said of the registered manager and deputy manager ‘their support has been amazing’.

The provider’s governance systems were not always efficient in ensuring information and records were accurate.

Notifications were not submitted as required to CQC in relation to Outcome of an application to deprive a person of their liberty (DoLS). A notification is information about an event or person which the service is required to inform CQC about. This was a breach of regulation 18 (Registrations). The registered manager had identified they needed to develop their knowledge of DoLS and had arranged for further training in this area for themselves and the deputy manager.

Service leaders completed a wide range of audits to monitor the quality and support the running of the service which included manager and provider audits. Audits reviewed a range of areas such as accidents and incidents, medicines, care plans, training and DoLS.

However, while some improvements had been made, further improvements were needed to ensure audits were as effective as they could be. For example, although the registered manager completed monthly care plan audits, we found several areas of people’s care plans contained out of date information. Medicines audits had not identified the areas we found during our inspection. Some audits were not signed, whilst some did not clearly record which documents had been checked and by who.

The registered manager had identified in their service improvement plan they required support to complete the plan to improve governance systems effectively. It had been agreed with the provider for the deputy manager to be allocated some time to assist the registered manager.

The service had displayed its CQC assessment rating on their website and at the service as required. The provider had a business continuity plan, to guide staff in emergency circumstances.

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 service encouraged partnership working. Staff supported people with formal reviews of their care with external professionals.

Professionals were positive about how the registered manager and staff team collaborated with them. One health professional said, “Carers know the residents well and will escalate appropriate concerns to us, assessing the person within their competency and taking observations to monitor and allow appropriate triage."

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 a service improvement plan to monitor progress with required improvements

Staff were encouraged to develop and were supported with opportunities to further their skills and training. Staff told us if they asked for additional training it would be provided.

The service had taken part in different pilot programs offered by local health services to improve care for people, for example senior carers had recently completed wound management training.

A professional told us, “I have seen great improvements in the service over the last few years which I attribute to the manager’s leadership."