Archived: 1 Lansdowne Road

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 the legal regulation in relation to governance. The provider had not always ensured their systems were effective in areas such as safe medicines administration, effective care planning, management of people’s health risks and environmental safety.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Overall, people experienced a positive culture with their day-to-day experiences of the care and support they received. They were supported to be part of their communities, and their independence was promoted. This promoted them to have control over their lives. People spoke positively about the support they received from staff. One person told us, "They (staff) do a lot for us guys."

During this assessment, the provider did not demonstrate their ability to manage all quality and safety risks. We identified a breach of the legal regulations regarding governance, indicating that the provider had not consistently recognised and addressed issues before our assessment.

However, there was a new Manager in place who was in the process of registering with the Care Quality Commission (CQC). Both the Manager and the Operations Manager acknowledged our concerns and understood the necessary steps for improvement. The Manager was in the process of making improvements to people's care plans. People and staff gave us positive feedback about the Manager. One person told us they liked the Manager's personality and stated they "make me laugh." Records showed the Manager had worked alongside staff and provided direct support to people. This allowed them to model the behaviours and practices expected from staff. A relative said, “I can ring [Manager] if needed.”
 

Our findings in the 'Safeguarding' part of the report indicated that, at this assessment, we could not be fully assured the provider would act promptly to protect people when concerns were raised about staff conduct.

However, people and staff we spoke with felt they could speak up if they had concerns. A person told us, "I feel safe, I would speak to [Manager] or [Operations Manager] if I didn't." A staff member said, “I feel free to raise any concerns.”

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 staff we spoke with during this assessment did not raise concerns to us about equality, diversity and inclusion. We reviewed previous staff meeting minutes which also did not show any concerns in this area.

The service did not always have good governance systems in place. We identified concerns related to medicines, safeguarding, IPC, environmental safety, care planning and supporting people with their health-related risks. We will check for sustained improvement at our next assessment.

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.

We saw evidence of external health professionals being involved in people’s care such as GPs, dentists and district nurses. The service produced a quarterly newsletter, available to people at 1 Lansdowne Road, celebrating their achievements and positive experiences, such as days out.
 

Although the provider was responsive to our feedback during this assessment, we could not be assured that the provider demonstrated they could make and sustain improvements at this service, due to findings such as those relating to not making improvements to fridge temperature records following an Environmental Health Officer's visit.
The Manager told us in relation to what else they felt needed to be improved at the service, “I think it needs a facelift, redecoration and a bathroom update.’’ However, staff and leaders told us when they raised areas of the home that needed maintenance they did not hear back from the provider as to when these improvements would be made.