Tollesby Hall Nursing 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

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 changed to 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 management team were visible, knowledgeable, and supportive, providing guidance to help staff develop in their roles. Staff told us they received the training they needed to carry out their roles effectively and felt confident in the support provided by the management team. A staff member told us, “We have a good staff team. We are friendly with and supportive of each other. The manager is supportive and approachable, and the culture is better since [they] took over.”

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 working at another home owned by the same provider. However, a new manager had been appointed who was in the process of submitting their application to register. The new manager had worked at the service as a clinical lead for 5 years so had in-depth knowledge of the people who were being cared for and supported at Tollesby Hall. People, staff and relatives spoke highly of the new manager.

The management team were knowledgeable and had good oversight of the service. Staff said they were supportive. When asked whether they were fair and approachable, all the staff we spoke to answered positively. A staff member told us, “Yes, the management team is approachable, experienced and knowledgeable about care standards. They communicate well and support staff development.”

The provider was good at fostering a positive culture where people knew they could speak up, and their voice would be heard. Policies and procedures were in place to make it easy for staff to speak up. All the staff we spoke to were aware of the process to raise problems and how to contact the provider if they needed to. When asked what freedom to speak up meant to them a staff member told us,” Freedom to speak up means I can raise concerns without fear. It is about promoting transparency, protecting people, and ensuring that concerns are listened to and acted upon.”

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 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.

At the last inspection in February/March 2023, we found the provider was not maintaining accurate and complete records concerning the service and people’s care. At this inspection, we found that improvements had been made.

There were now stronger governance systems used effectively in the home. Audits and checks were carried out regularly such as audits of care records, health and safety and staff practice. Quality reviews were completed in line with regulatory requirements. The manager maintained oversight of all audits and checks and progress with improvement action plans. Electronic systems and robust monitoring tools were utilised to monitor, for example staff training or day-to-day care provided to people. The manager understood the legal requirements of their role and the importance of their role and responsibility. They had submitted an application to CQC to become registered as the manager of the service.

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 worked in partnership with other health and social care professionals to meet people's needs. Records evidenced appropriate healthcare referrals and appointments.

A visiting professional told us, they visited the home to work with staff and people to look at postural screening, assessing the body alignment and movement to spot imbalances or deviations that may lead to pain or injury. They told us, “When delivering training sessions regarding postural alignment, staff attended and contributed to the sessions with interest. I do not have any specific concerns with Tollesby Hall, quite to the contrary as I am always made to feel welcomed.”

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 management team had worked hard to ensure improvements were made in areas highlighted at the last inspection. They ensured staff were supported to keep up to date with developments in best practice to ensure they were providing good quality care.