Louth Manor Care Home

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. This is the first assessment for this service. This key question has been rated 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 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. Staff understood the goals of the organisation and worked in line with its values. They promoted equality and demonstrated compassion and monitored outcomes against their strategy.

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. Staff told us they felt supported by the management team and felt there was a positive culture at the service. One staff member told us about reasonable adjustments the registered manager had put in place to better support them to do a good job.

People and relatives also spoke highly of the management team. A relative told us, “I have spoken to the [deputy manager] many times; they are very available.” Another relative said, “I would rather go direct to [the registered manager], they have always been excellent, their door is always open.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People relatives and staff all told us they felt able to speak up. The provider implemented various methods to facilitate this from formal surveys and meetings to informal chats and an open door policy.

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. All staff we spoke with confirmed they were treated fairly and respectfully by leaders. They told us there were no inequalities in respect to pay, job roles or treatment.

The provider had clear responsibilities, roles, systems of accountability and overall governance was good. However, care was not always of the expected quality in relation to staffing levels and concerns with the call bell system had been ongoing since December 2024. Governance systems had not identified the concerns we found in relation to risk assessments and people told us improvements were not always sustained. The registered manager did act on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The registered manager and other senior managers were passionate about continuously improving the quality of care and responded openly and proactively to our feedback.

People and relatives told us they felt communication could be better but overall though the service was well managed. One relative said, “It is very well organised. Every morning at ten, they have a meeting and discuss the people. I think it’s very well run; the only negative is I think they need more staff.”

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. They ensured people had access to GP. Nurses, dentists, opticians and other health professionals. Professional gave positive feedback about the managers, staff team and quality of care. They felt they all worked well together and with external agencies and staff knew when to escalate concerns to community teams for advice or support. A professional told us, “I have a very good relations with all the staff at Lough Manor, especially the management team. I have seen high quality care being given by the staff team.” Another professional said, “I had no concerns about care that was being given. People appeared happy with the care they were receiving and care plans appeared person centred.”

The provider focused on continuous learning in relation to staff training and qualifications, innovation and identifying areas for making improvements across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. The service had systems in place to analyse incidents, monitor quality and inform improvements. They created strategies that encouraged staff to fulfil people’s dreams and wishes and were continuously searching for new ideas and new ways of working. They encouraged people and staff to make suggestions for improvements.