Lonsdale Mews

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 remained as 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.

The service had clear visions and values which they communicated to staff. Staff supported these values and were able to describe how they put them into practice. Staff and leaders had a positive listening culture and people felt safe to raise concerns or share any worries. Staff gave good examples of how they promoted equality and diversity across the service.

Staff members spoke highly of the registered manager. One staff member told us, “[Registered manager] is incredibly understanding and approachable. Whether it is addressing personal challenges or workplace concerns, he ensures that I have felt heard and supported, creating a positive and inclusive atmosphere.” The registered manager told us they were well supported by the regional director, who visited the service frequently.

The provider participated in recognition events, with the registered manager winning an award internally, and another award externally.

Staff told us leaders listened to them and worked collaboratively with them when they raised concerns. Staff understood how to escalate their concerns if they felt their concerns had not been addressed appropriately. The registered manager encouraged a positive culture of openness by being present in the service and having an open-door policy.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Following the assessment, the registered manager contacted us to provide assurances of the actions they would take moving forward to drive improvements in the service in the areas of concern we identified.

The providers systems and processes had not identified the shortfalls found at this inspection. Lessons learnt following accidents and incidents were not always clearly documented, there was some missing information in respect of some people’s DOLS conditions, some care records did not adequately support staff to mitigate risk, best interest decisions lacked important details and there was a lack of robust information to support staff to administer when required medicines.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager told us the whole staff team had worked hard to build relationships within the local community. A book group had been set up which linked in with the local library, and a local religious minister visited the service regularly to hold religious services for people who wished to attend. The service had also worked closely with a global volunteer movement to support a local foodbank. The service had also raised a significant amount of money for a dementia charity, with 7 staff members participating in a skydive.

The provider was underway in achieving accreditation in the Gold Standards Framework, and working towards an accreditation with Care Fit for VIPS to support people with dementia at the time of this assessment. The service was also working towards the Veterans Friendly Framework to enable them to support people who had served in the Armed Forces.