Lenthall House

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

Staff and leaders fostered a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service. The manager had instilled a positive working culture at the service. This was supported by our observations and feedback from people, relatives and staff.

The atmosphere was homely and welcoming. Staff were consistently available to people and were polite and courteous in their approach. A person told us, “Everyone is very friendly and helps you." A second person said of the manager, "A very nice gentleman. He's very friendly with everybody."

Relatives consistently spoke with high praise of the changes they had noticed since the appointment of the manager. A relative told us, “The new manager is very nice and much friendlier, and we have smiles back in the building. He speaks to residents and families by name. I am really grateful he is there.” Whilst another relative said, “The new manager is fitting in really well and has a much higher visibility. He is accessible and approachable towards everyone; it is creating a lovely atmosphere.”

Staff were overwhelming positive about the atmosphere, which created a positive working culture. A staff member told us, “I cannot tell you how nice it is to be listened to, and he takes action. He genuinely cares, and he stayed overnight when we had a new resident who was unsettled. He cares about families’ residents and staff.”

The provider’s analysis of staff questionnaires evidenced staff felt supported, listened to and valued by the manager. Staff documented their positivity to the improvements made since the appointment of the manager. Staff feedback was that of working effectively as a team, and enjoyed their caring role, for which they felt sufficiently trained. Staff were positive about improvements to the culture and reported their views were listened to.

The managers shared their key values of the service, as being collaboration and teamwork, accountability, inclusion and transparency. The shared values were sustained through the development of strategic goals, to support outcomes for people, and to develop and support the team.

People and staff were supported by capable and inclusive leaders who had the skills, knowledge, experience and credibility to lead effectively. The manager understood their role and responsibilities, and received ongoing support from their line management team.

People and relatives spoke highly of the manager. However, some relatives continued to lack confidence in the provider. A relative told us, “There was a big meeting organised by the owners and we were promised all sorts, very little of which has transpired. Doesn’t seem they are about to invest in the home.”

Staff spoke well of the manager, area manager and head of care operations. Staff said they were approachable, supportive and lead by example. A member of staff told us, “We do see the head of operations and area manager. They have both been supportive, and give advice, clarification and support.” A second staff member said, “The manager is a guy that stays over his time if he has something to finish off. He helps to improve things. He speaks to the residents and family members.”

The head of care operations made themselves available to support the manager with the inspection. They spoke of future plans for the service and the wider organisation, and remained open and transparent about things they felt still needed to be improved.

The manager has applied to register with the Care Quality Commission. The post of deputy manager has been advertised, and an interim deputy manager is in post, who is being sponsored via the provider’s leadership and management developmental programme.

The manager shared their thoughts on the direction and culture of the service, they advised team meetings were regularly held to share both the values and goals. Staff were acknowledged and rewarded for embodying the values, which were determined through feedback and peer recognition. We observed members of staff receiving certificates, and their success was celebrated by both people and staff.

The manager confirmed they were extremely well supported by the head of care operations and the area manager, and referred to the bi-annual progress meetings with the CEO, which included the senior management team. The manager advised opportunities were available for them to gain and refresh their knowledge through internal and external training.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were aware of the provider’s policies and procedures which supported them to raise any issues relating to poor practice, concerns and complaints. A member of staff told us, “We can say what we have concerns about, without stress.” A second staff member said what freedom to speak up meant to them. They said, “It means if I have any problems or issues, it is my right to say, and if don’t want to confront it myself, I can go through whistleblowing (process).”

The manager informed us there was a clear whistleblowing policy which staff were made aware of during induction and ongoing training. They advised an open and supportive culture encouraged staff to speak up without fear of reprisal.

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’s policies and procedures supported equality, diversity and inclusion in the workforce.

The manager understood their responsibilities in line with the Equality Act 2010 and its implications for employees. The registered manager was aware of their role in upholding the principles of the Equality Act. They informed us the provider’s policy and procedure for equality, diversity and inclusion was shared with staff at induction, training and reinforced at staff meetings and supervision.

The manager was aware of potential adaptations which could be considered to support staff. Examples included a special type of keyboard to support people with a visual impairment or to support a person living with arthritis, or adaptive lighting to reduce sensitivity.

The provider had clear responsibilities, roles, systems of accountability to support good governance. However, the effectiveness of audits could be improved to ensure improvements identified were clearly documented and monitored in support of timely improvements.

Relatives did acknowledge some of the environmental improvements made. However, some spoke of improvements previously promised by the provider, which had not as yet been achieved. A relative told us, “Going forward, the senior management (company) would do well to adopt dated goals, otherwise they mean very little and get forgotten or glossed over.”

People’s views and that of their relatives and staff were sought through meetings and questionnaires. Minutes of meetings recorded relatives views regarding environmental improvements. The outcome of surveys were in the main positive, areas for improvement identified included the environment and outside courtyard area.

The manager completed audits covering a wide range of areas, which included infection control, medication, mealtimes and kitchen audits. However, audits were not consistently robust to drive improvement. For example, medicine audits had not identified the concerns raised by an external stakeholder. In response, the medicine audit template had been reviewed and updated.

Audits which had identified shortfalls, could be further improved so as to be more effective and detailed in recording the actions being taken to bring about improvement and the progress of the actions. The manager and head of care operations said they would review how audits were used to record information. The area manager as part of their role regularly visited the service, which included auditing. The area manager produced a report detailing their findings, along with an action plan. Audits and reports undertaken by the manager and area manager were reviewed by the head of care operations.

The manager was aware of the need to inform key stakeholders, including the Care Quality Commission of events and incidents. The manager had a good understanding of their responsibilities around health and safety, the overseeing and reporting of safeguarding, quality assurance and risk management. Along with ensuring staff training and competence.

The management team and staff 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.

Relatives confirmed staff worked collaboratively with external organisations to support good outcomes for people. A relative told us, “The district nurse and the GP both have a good relationship with the home and visit regularly.”

The manager informed us the staff team worked collaboratively with partner agencies, such as healthcare professionals, local authorities and training providers by sharing information during multidisciplinary meetings and care reviews, and that this approach enabled the staff team to learn from wider expertise and ensure co-ordinated support for people.

Records showed staff had contacted a range of health and social care professionals. This enabled people’s health and wellbeing needs to be assessed and continually reviewed to ensure people’s individual needs were met.

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 manager informed us training had recently been completed on the Whzan System. The aim is to empower non-clinical staff to take observations, such as temperature, pulse, oxygen saturation levels and blood pressure measures. The necessary equipment to be provided, enabling staff to monitor deterioration, providing greater detail when communicating with health care professionals, including NHS 111 and GP’s.

Further areas for development include a greater use of technology including the introduction of an electronic medicine monitoring system to improve safety and support efficiency.

External agencies informed us representatives from Lenthall House attended provider forums organised by the local authorities, where updates and contract information was shared.