Astor Lodge

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 inspection we rated this key question requires improvement. At this inspection 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 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. New staff received support and training which helped them to demonstrate the provider’s values in their daily work with people.

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 had made several improvements to the running of the service. People and staff were complimentary about the management team. Their comments included, “The manager is accessible”, “The managers are approachable, they introduce themselves, they would come if needed. The carers and nurses are the contacts.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. They had a clear whistle blowing policy. Staff could raise concerns, and written information was available of how to do this. Staff meetings took place, and staff had the opportunity to share comments and give feedback. People were informed of the complaints procedure when they started to use the service and at meetings. A staff member told us, “We can share suggestions, and we are asked for our views.”

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 told us they were able to ask for reasonable adjustments to be made to their working patterns for specific needs, for example to incorporate family commitments.

Governance was not always effective. The service had clear responsibilities, roles, systems of accountability and better governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on information about risk, performance and outcomes, and shared this securely with others when appropriate. Regular audits and checks were carried out in the main areas of the service, such as, care records, health and safety and staff practice. Audits showed action was taken where areas of improvement were identified. However, some audits such as in care records, staff deployment and other areas identified during our inspection needed to be more robust and more frequent, to ensure the quality of service provision.

Staff at the service 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. A person told us, “Staff seem to work as a team.” All professionals fed back the service worked in partnership with them. A healthcare professional commented, “Staff participate in group activities with the patients and therapist as well and report any concerns to the multi-disciplinary team (MDT).”

The provider and management team 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 contribute to safe, effective practice and research. There was evidence of changes that had been made to the service to make improvements and to address checks and audit outcomes and in response to people and staff feedback. However, we identified further improvements were needed in areas as described in sections of the above report. External quality assurance arrangements were in place to monitor the internal governance systems.