Vaughan Lee 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 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. At the last inspection we found a breach of regulation in relation to good governance. At this inspection we found improvements had been made and they were no longer in breach of regulations. However, further improvements were needed to ensure the quality monitoring systems were always robust and led to improvements where needed. The provider took action following the inspection visit and informed us of how they would be addressing issues raised.

This service scored 68 (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. People told us they felt very ‘at home.’ This showed a relaxed and inclusive culture. One visiting relative told us how their loved one was able to carry on with the routines they had before moving into a care home. Staff said they aimed to create an atmosphere where people were relaxed, comfortable and continued to make choices. More than one person told us they would recommend the home to other people in a similar position to themselves. One person commented, “No doubt about that. I would recommend.”

People lived in a home where leaders had the skills, knowledge and experience to lead effectively. Leaders were visible and led by example to share good practice and inclusive behaviours. The registered manager had the skills and experience to effectively lead the home. The nominated individual was also very visible and had a commitment to making improvements. The nominated individual told us they had joined a forum to expand their knowledge and experience. Since the last inspection the provider had arranged for leadership training for senior staff to enhance their skills.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People and staff said they would be happy to raise any issues. All were confident that action would be taken in response to concerns raised.

The provider valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff spoken with felt valued and respected. All thought it was a good place to work.

Further improvements were needed to ensure the provider had clear and effective systems of governance to support the delivery of good quality care to people. Since the last inspection improvements had been made to how quality was monitored. The provider had worked with other professionals to identify shortfalls and plan improvements. They had devised a service improvement plan which had led to identified shortfalls being addressed. However, we found some audits carried out by the provider were not leading to the implementation of improvements. For example, an audit of call bell response times had identified that some people had waited a long time, but no action had been taken in response to this audit. Also, an environmental audit had not led to the minimisation of a risk we identified. Audits of care plans had not explored the care provided to people to ensure the records were reflective of people’s current needs. Following the inspection visit the provider sent evidence of how this would be improved. They had worked with the registered manager and training provider to make sure audits were more robust going forward. Further training was being planned for staff to make sure care plans were fully reflective of people’s care needs. There was a clear staffing structure which ensured there was always a senior member of staff at the home. This meant they were able to lead by example and monitor the quality of care provided to people.

The provider understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. People continued to be part of their local community if they wished to be. There was a minibus which enabled people to participate in local events. The provider worked in partnership with others to meet people’s needs. For example, one person told us there was a church service at the home which was important to them. Staff said they would be happy to arrange anything which supported people to continue to follow their chosen faith or lifestyle choice. The registered manager and provider were part of local forums which enabled ideas to be shared.

Improvements were needed to make sure people using the service, their families and carers were fully involved in developing and evaluating improvement and innovation initiatives. There were some meetings for staff and people who lived at the home. This enabled people to share their ideas and make suggestions. However, meetings for people were not frequent and there was no information to show how suggestions had been used to make changes or improvements. Although audits had not always led to improvements the provider had listened to people and staff to plan and implement some improvements. For example, some changes had been made to staff shifts in response to suggestions from staff.