Lansdowne Hill Care Home

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• 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

In this key question we assessed 5 quality statements. Current leaders had the skills and experience to oversee the service safely, however, this was an interim arrangement until a new manager was permanently recruited. There was a culture of continuous improvement and reflection. Staff spoke positively about the current management arrangements and felt confident that any concerns would be listened to and acted on. The service worked well with other professionals. However, we found 2 incidents which has not been reported to the Commission, in line with their legal duties, and found audits had not been effective in identifying the concerns found during the assessment.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders explained how they promoted the company’s values and vision. They told us, “It’s really about people and what’s really going to help people, the difference in changing a person’s room and painting a door, to really understanding why a person has fallen over. You can have the corporate values, but what’s been helpful, is by us leading and directing the team, staff are happy with how hands on we’ve been. We’re out there promoting people.” Staff felt there was a positive culture within the service and felt able to address any concerns with leaders.

The service had core values, a vision and a mission statement in place and these were displayed visually throughout the service. Leaders discussed these with staff during supervision and appraisal meetings.

Staff spoke positively about the current management arrangements. Staff described current leaders as approachable and supportive. One staff member told us, “I do feel very supported and safe with [current interim managers].” Leaders explained how they upskilled staff to support their development. Leaders gave an example of offering support to a staff member who had not raised a safeguarding referral before, to ensure they felt competent to do so again in the future.

Staff in leadership positions had completed additional training relevant to their role. Leaders were knowledgeable about the issues and priorities for the quality of the service. Leaders had the skills, knowledge, experience and credibility to lead effectively.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Leaders told us about the systems and processes which were in place to ensure the service ran smoothly and effectively, such as audits, handovers, team calls with managers, manager walkarounds, analysis of data, service development plans and action plans. Staff were able to tell us about the various audits which took place within the service.

We found 2 incidents which had not been reported to the Commission, which is a legal requirement. We raised this with the current interim managers, who explained that one incident occurred under previous management. However, the other incident occurred whilst the current leaders were overseeing the service. All other relevant actions had been taken such as making a safeguarding referral and sending a duty of candour letter. Leaders explained how they had made improvements to oversight in relation to the reporting of incidents to CQC. One leader told us, “I have been working with the new deputy manager helping her through her induction and processes, so that she is aware of how and when to report. We have an escalation email that is sent to the manager and deputy for all incidents for them to check through and sign off that all necessary actions are completed. We discuss incidents in our daily stand-up meeting and share lessons learnt.” The service conducted regular audits, and these appeared to be effective in some areas. However, the service had not identified large gaps between documented care records and therefore had not addressed these with the team prior to our assessment. We raised this with leaders, who implemented a new process to ensure better oversight of this in the future, including more regular observations of care and a new daily audit looking to see if care had been completed in line with people’s care plans.

One relative told us they had been waiting a long time for a medical appointment for their family member to be arranged. We raised this with the provider who told us this appointment had now taken place. The leader told us, “The relative is aware as they have been supporting their [relative] to attend the appointments. I believe their frustration was prior to me being at Lansdowne that they had made previous requests to Management and felt nothing had been actioned.”

Staff and leaders told us how they worked well health professionals such as GP’s, social workers, district nurses and the dementia later life liaison team and the speech and language therapy (SALT) team. Leaders gave examples of how they promoted community engagement within the service, such as people attending the local farmers market and church service. Leaders explained how they share ideas with other care services through a forum set up by the local authority. One leader explained, “The meetings are held in care homes which take it in turns to host. Both activity coordinators attend where they can network, share ideas and experiences with each other.”

One partner told us: “[Deputy manager] is an excellent leader, compassionate carer and one of the best [person] advocates I have seen. Her recent promotion into the deputy manager role will see Lansdowne flourish and fills me with confidence that they will be looked after well and go from strength to strength. [Leader] who was acting manager at the time had an amazing open-door policy and was keen to improve and regularly approached nursing professionals for training opportunities for her staff so they could improve.” This partner also described staff as responsive to people’s needs, and felt staff knew people well. They told us that some staff were not as confident in escalating concerns to the GP, however felt leaders were willing to listen to concerns to address them.

Processes were in place to ensure good engagement with partners, such a multi-disciplinary team meetings and engagement with local authority initiatives.

Leaders told us about how they encouraged staff to reflect following incidents to encourage learning. For example, asking staff what they could have done differently following the review of incident forms and asking staff to reflect. Additionally, leaders explained how they gathered feedback from staff, people and relatives to improve the service. Some staff felt leaders were open to new ideas, however, one staff member told us, “I have approached [leaders] over certain things, and it hasn’t got done.”

Processes were in place to encourage learning, improvement and innovation. For example, an online system was used which allowed leaders to analyse data and to investigate the root cause of incidents and accidents. Regular surveys were conducted within the service and actions were taken following this feedback. This allowed for a culture of continuous improvement within the service.