Sutton Hall and 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 inspection we rated this key question requires improvement. At this inspection the rating has remained 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 at the service.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We found the provider open and transparent. They demonstrated a willingness and desire to improve the service. Following a recent local authority visit, the provider had put in place a detailed action and improvement plan. Following our inspection, they reviewed and updated these to include concerns found during our inspection. They also put in place further action plans for support for managers and continued improvements.

Relatives spoke of an openness and transparent culture.

The provider understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Managers shared a commitment to providing person centred care and the improvement of the service.

Staff, and people who lived at the home, told us managers were very approachable. One staff member said, “I find [manager] nice and [manager] is easy to approach.”

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

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 and management team did not have clear responsibilities, roles, systems of accountability and good governance. There were audits in place, however these had not been sufficiently robust or effectively used and had not identified the concerns found during the inspection or ensured appropriate action was taken. This included concerns regarding medicine records and management, DoLS, capacity and consent and supervision. The provider had a clear structure and overview for audits, governance or oversight. However, this had not been consistently and effectively implemented. There was no evidence of ongoing analysis or lessons learned, overview for records of safeguarding’s and complaints were not fully completed.

Policies and procedures were in the process of being updated.

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 provider discussed with us their commitment to 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.