Laurel Court (Didsbury)

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 good. At this assessment the rating has changed to 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 governance and oversight.

This service scored 61 (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 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.

Managers demonstrated a clear understanding of their roles and the goals of the provider. However, staff were not consistently aware of their responsibilities, particularly in relation to accurate reporting and recording which required further clarity. Evidence did not always show that staff were actively engaged in contributing feedback during meetings, supervision, changes within the home and records did not consistently reflect a culture of two‑way communication and shared accountability.

Staff said, “The managers say that all staff should move around the floors and be more flexible, but in reality, it’s only some staff being moved and some staff are staying. They didn’t really communicate this to staff. When we come in to work, we go to the floor to see our rotas and just get on with it. I’m not sure why but rather than personality clashes, I think there’s mainly a skill mix problem. I can end up in a situation where I’ve done 3 to 5 residents personal care when another person has only done 1 -2.”

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.

The registered manager was experienced and knowledgeable. They demonstrated a clear understanding of the requirements associated with their registration with the Care Quality Commission (CQC) and brought extensive expertise in managing care homes.

Other leaders across the home were appointed based on their experience and had undertaken additional training to strengthen their skills. Staff were supported to develop into leadership roles and were provided with opportunities to complete further training and gain relevant qualifications.

Staff said, “I have just finished my NVQ Level 3. I asked to do this, and they (the provider) supported me.”

People did not always feel they could speak up and that their voice would be heard.

Staff shared that they felt able to speak up, but many chose to raise concerns with administration staff rather than the management team. While some staff had voiced worries about ongoing building work, agency staff, and staffing levels directly to managers, others hadn’t and didn’t explain why.

When we reviewed staff meeting minutes, it appeared that opportunities for open, two-way dialogue were limited. Staff said they attended meetings, but often felt the focus was on what they weren’t doing well, rather than celebrating their contributions and successes.

Staff surveys had been distributed and received some responses. However, meeting notes showed staff were encouraged to include their names on the surveys, which may have discouraged honest feedback by removing anonymity.

After staff feedback was shared with the provider, they took steps to strengthen support by arranging HR workshops. These sessions were designed to help staff feel heard, valued, and better equipped to raise concerns confidently and constructively.

Staff said, “There are staff meetings once a month at set times. Sometimes I can attend but there is not enough staff on the floor. I don’t feel comfortable to suggested improvements all the time. Sometimes I will voice my opinions.” and “Staff meetings are every 3 months, with the manager, deputy and residential manager, they talk about concerns on each floor, new rules and changes.”

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 employed a diverse workforce who benefited from rewards and benefits including flexible working patterns, well-being support, employee assistance programmes and retailer benefits. The organisation promoted workforce equality and staff felt they were treated with respect.

Staff told us they had been supported well when dealing with private concerns outside of their employment.

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.

Governance audits were regularly completed; however, they had not always identified where improvements were required. There were gaps in recognising a lack of recording in daily notes, and care plans were not consistently reflective of people’s current needs. For example, one care plan stated that a person was independently mobile, while another recorded that they required hoisting. This inconsistency had not been identified through audit processes, although staff were aware of the person’s actual needs.

There were also failures to identify risks in medicines management, which exposed people to the possibility of receiving their medicines unsafely. In addition, ongoing building work was not continually assessed to ensure the safety of people living in the home, staff, and visitors. These issues highlighted weaknesses in governance systems, where audits did not always provide effective oversight or assurance of safety and quality.

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 external organisations and local community groups to strengthen outcomes for people. Feedback from partner agencies were positive. Engagement with families, advocates, and community representatives helped ensure that people’s voices were heard and that care was responsive to diverse needs.

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.

Systems were in place to capture lessons learned from incident audits, and these were used to drive service development. The provider had implemented a falls monitoring system that effectively identified patterns and locations where recurrent falls were occurring. This enabled the provider to conduct targeted reviews of environmental factors contributing to such incidents. For instance, 1 person was frequently falling while attempting to reach their television remote control. In response, the remote was repositioned to a more accessible location, thereby reducing the risk of repeated falls and enhancing the individual's safety.