Lychgate 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 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.

The registered manager and provider were committed to maintaining a positive and person-centred culture. They shared their values and expectations with staff through team meetings, supervision sessions and daily handovers. Staff spoke positively about the leadership of the service and described an open and supportive working environment.

A staff member told us, “I feel supported and valued as a team member at Lychgate House. I feel comfortable approaching my colleagues, senior staff, and the management team for advice, guidance, and support whenever I need it.” Another staff member said, “I feel appreciated because our directors encourage staff to share ideas and continuously look for ways to improve the quality of care. This creates a positive working environment where everyone works together to achieve the highest possible standards for our residents.”

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. They did so with integrity, openness and honesty.

The registered manager was highly visible and supported staff with day-to-day care provision. A person told us, “I can talk to the manager about anything I am worried about.” A relative told us, “The manager is lovely to speak with, and I have found them, as well as the rest of the staff team, to be welcoming, approachable, and professional.”

Staff felt supported by the registered manager and the directors visiting the service. A staff member told us, “Our manager is firm on safety rules, safeguarding service users and making sure care is person centred. Staff feel empowered and this ensures all staff carry out their job effectively and safely. Another staff member said, “I believe the management team is caring, approachable, and understanding.”

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

The provider had a whistleblowing policy in place and staff received training on how to raise concerns. Staff were able to explain the correct processes to follow and told us they felt confident they would be listened to if they reported concerns about people's safety, wellbeing or the quality of care.

Staff spoke positively about the culture within the service and the support they received from leaders. A staff member told us, “Our directors are approachable, supportive, and actively encourage staff to report any concerns regarding poor practice or abuse.” Another staff member said, “We are encouraged to speak up about poor care without fear.”

The feedback we received indicated leaders promoted openness and transparency and encouraged staff to raise concerns, share ideas and contribute to service improvement. This helped create an environment where staff felt supported to advocate for people and maintain high standards of care.

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 had policies and procedures that protected staff from discrimination and promoted equal opportunities. Staff consistently told us they were treated fairly and raised no concerns about discrimination. They told us, “Our approach is to recognise staff may have different needs and circumstances and to provide appropriate support while maintaining fairness across the team. We believe valuing diversity within our workforce strengthens the service and helps us provide better, more culturally aware and person-centred care to our residents.”

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 registered manager and provider had made improvements since the previous inspection and were no longer in breach of regulations. They now maintained an effective range of quality assurance systems, including audits, checks and reviews of care records, medicines, incidents, accidents and the environment. Where audits identified areas for improvement, action plans and timescales were developed and monitored to support continuous improvement.

Leaders reviewed information relating to risks, performance and outcomes and used this to inform decision-making and service development. Staff understood their roles and responsibilities and were supported through supervision, team meetings and regular communication to provide care in line with best practice and organisational expectations.

Governance systems helped ensure people received care that reflected their needs, while promoting positive outcomes and continuous improvement within the service. The provider had a business continuity plan for staff to follow in the event of emergency or natural disasters, such as adverse weather events.

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 service actively supported people to access healthcare appointments and maintain links with their local community. A person told us, “The nicest thing about being here is staff are easy going. There is not anything here I could make better, staff take me to the GP, dentist etc.”

Feedback from relatives and staff indicated the provider made appropriate referrals and took reasonable steps to progress requests for support when people's needs changed. As noted elsewhere in this report, some feedback highlighted challenges in accessing healthcare professionals in a timely way due to waiting times within external services. However, there was evidence the provider followed up referrals, liaised with relevant professionals and continued to monitor people's wellbeing while waiting for specialist input.

The provider also shared relevant information appropriately with partner agencies and used learning from external professionals and services to help improve outcomes for people. This collaborative approach supported continuity of care and demonstrated a commitment to working in partnership to meet people's needs. The service kept an overview of all positive comments made by visitors to the service including professionals, 1 had commented, “The establishment seems well led and organised and I would recommend Lychgate house to potential residents, staff and fellow health professionals.”

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.

Leaders actively sought feedback from people, relatives and staff and used this information, alongside audits and quality assurance processes, to identify opportunities for development and drive improvements across the service.

The provider encouraged a culture of reflective practice where staff were supported to learn from incidents, complaints, compliments and feedback. Lessons learned were discussed through team meetings, supervision and daily handovers to help improve outcomes for people and reduce the risk of concerns reoccurring.