Wellesley 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 clear vision to provide high-quality personalised care. This was shared by the staff team. The provider told us, “We need to deliver our best for people’s loved ones. My priority is to make sure they settle and spend their last days with dignity, respect and happiness they deserve.”

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 new to their role but was being supported by an experienced management team across the provider group. The registered manager had good oversight of the service and was providing clear leadership. Staff confirmed the registered manager was approachable and accessible. They set clear standards and had introduced shift allocation sheets which gave clear instruction about what areas of care delivery individual staff were responsible for.

People and relatives also told us the management team were welcoming, approachable and visible throughout the service. Comments from relatives included, “The management are so open and welcoming and listen to any concerns. They keep a very professional attitude. They still come across as friendly and approachable at all times.” And “[The registered manager] is readily available when we visit or if I call. She is always receptive and available for discussions about my [family member’s] care.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People, relatives and staff felt comfortable speaking openly with the management team and they were encouraged to express their views during one-to-one meetings as well as staff and group meetings. A whistleblowing policy was in place. At the time of our assessment the provider did not have a freedom to speak up guardian in place. They told us they would consider nominating someone to this role to strengthen support for staff to speak up.

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. An equalities and diversity policy was in place and staff were supported to work in an environment that was free from discrimination.

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 registered manager undertook a regular programme of audits and monthly review of key service data to ensure they had oversight of the quality and safety of service delivery. This information was used to inform continuous improvement. Key service data was analysed to identify any themes or trends that indicated improvements were required.

The provider was also working with a third-party provider who undertook mock CQC assessments which offered an independent review of the quality and safety of care provision.

The registered manager was aware of their CQC registration responsibilities and submitted statutory notifications about key events that occurred as required.

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. Staff worked in partnership with people, relatives, staff and visiting professionals to meet people’s needs. Staff welcomed feedback and advice and used this to improve practices.

The registered manager attended the local authority’s provider forums and had built links with other local care home managers to share ideas and best practice.

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.

There was a clear focus on improvement and learning at the service. It was a newly established service, and the management team were committed to developing the service. They held regular meetings with staff to obtain their views about the service and where improvements and developments could be made. There were plans in place to introduce a key worker system, to give staff clearer lines of responsibility for people’s care and to enable a more detailed focus on people’s care.