Sutton 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.

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.

New posters had been displayed to demonstrate the providers vision and values. Staff were provided with keyrings with the providers values on to ensure they always treat people in line with the providers’ vision. Relatives and staff told us they would recommend this service to people. A relative said, “I would highly recommend it here.” And a staff member said, “I would recommend to anyone who wants to work with individuals with dementia.”

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.

Management changes had taken place since our last visit. This assessment demonstrated that managers had the necessary skills, knowledge, and experience to carry out their roles effectively. For example, care plans had been updated and audits identified concerns, risks, and areas requiring improvement, enabling appropriate action to be taken. This meant the service had effective leadership and oversight to support safe care.

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

The provider had a range of processes in place to enable staff to speak up, including an open-door policy, a suggestion box, one-to-one supervisions, and staff meetings. Staff told us they felt they could raise concerns and would be listened to. One staff member said, “I would feel comfortable raising a concern; the manager would listen. I know how to whistle blow, as I would not tolerate poor practice, but I have never had to.” This demonstrated that staff felt supported to speak up and raise concerns when needed.

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.

for people who worked for them.

Staff had completed equality, diversity, and inclusion training. Rotas were reviewed, and staff were involved in decision-making. We were told staff had agreed to change the rota patterns to make them fairer and more equitable.

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 revised management structure was effective and provided oversight of the service. Governance systems were in place this included, monthly audits and management meetings, that had identified and addressed concerns promptly. Systems were also in place to review and analyse incidents, falls, and people's fluid intake, this had helped to improve the safety and effectiveness of care people received. There was a range of policies in place and provided staff with guidance. There was regular staff meetings that had taken place to discuss key aspects of the service, this included the environment, housekeeping, meals, and people's care needs.

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.

Improvements had been made and we found reportable incidents were appropriately shared with external agencies such as the CQC and local authority safeguarding team when required. Processes ensured relevant health professionals were involved when they required health care. Appropriate advice and support were sought from healthcare professionals, helping to reduce risks and promote people's safety and wellbeing, such as such as directed nurses for skin damage.

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.

The provider demonstrated a commitment to continuous learning, and improvement. Changes to the management structure had strengthened leadership and oversight. Feedback from people, relatives and staff was actively sought, reviewed and used to drive service improvements. Audits of incidents, falls and other quality assurance processes was used to identify trends and improve outcomes for people.

Staff were encouraged to contribute ideas and improvements through meetings, supervisions and an open culture. Changes to rota patterns were made after staff consultation to promote fairness and equality.

The provider worked collaboratively with healthcare professionals and external agencies to support safe and effective care. Governance systems and regular reviews supported continuous improvement and helped ensure people received safe care.