Lee Gordon 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 good. At this assessment the rating has remained 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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff were positive about the changes made since the new manager and deputy had started. Comments included, “The manager and deputy encourage us to make suggestions, it’s about working together,” and “We have team meetings and one to one meetings. You can say what you think or what’s on your mind.” Staff spoke about the training they received and were confident in their roles. Both the deputy and manager told us they felt supported in their role and had opportunities for personal development. The manager told us, “I get lots of support from the area manager and wider management team.”

The management team had identified areas for improvement prior to our visit and an action plan was in place to drive forward these improvements. While systems and processes were in place to monitor the quality and safety of the service, they were not always effectively operated or embedded as they had not highlighted some of the issues we found for example, plastic latches fitted to the fire doors and the lack of cleanliness in some areas of the home. Other audits and checks in place to monitor the service were effective to drive forward improvements. For example, checks on care records, staff competencies and the provider’s improvement plan for the home. New staff received an induction and training to ensure they had the necessary skills for their role. For example, staff completed epilepsy, fire safety and moving and handling training. Staff told us they found the management team to be approachable and supportive and were available to them, when needed out of hours for any advice. Team meetings were used to discuss any concerns raised, share lessons learnt and to review and follow up on any previous actions introduced to drive forwards improvements in the service.

Staff told us they felt confident raising any concerns to the management team and were confident action would be taken to address them. One staff member said, “I think people are safe and happy. That’s our job and aim, [People’s names] can speak up for themselves you would know if they were unhappy, or something wasn’t right.” Staff confirmed they attended team meetings and had the opportunities to share their views about the quality of the service. People and relatives were encouraged to raise complaints and concerns so they could be addressed, and the procedure and contact details were shared with them. Feedback was also sought from people during resident meetings and informal chats with relatives.

The provider held regular team meetings, where staff had the opportunity to raise concerns and offer suggestions. The management team had shared information about where improvements had been needed with staff and teamwork had led to some of these improvements being achieved. However, further time was needed to fully embed these systems and processes following the recent change in the management of the service. The provider had sent out quality questionnaires to gather feedback from relatives and their responses had been collated, any suggestions to improve the service were included in the action plan to further improve service delivery. The management team were supportive of this assessment and shared information where they had identified further work was needed to continue driving forward improvements to enhance the quality of the service. The management team were open and receptive to our feedback and suggestions made during the assessment. The manager understood the need to be open and honest when things went wrong in line with the responsibilities under the duty of candour.

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.

Staff understood how to report any incidents and the importance of doing so. Staff demonstrated an understanding of their roles and responsibilities and told us they received support through supervisions and regular team meetings. Staff felt the management team were accessible to them and told us, “The managers are very helpful,” and “Things have changed for the better since the new managers have started.”

The provider had not always ensured people’s sensitive information was held securely, in line with the General Data Protection Regulation (GDPR) as we found some people’s care records stored in an unlocked store cupboard ready for archiving. The manager took immediate action to address this shortfall during our visit. Systems and processes to monitor the quality and safety of the service were not always effectively operated or embedded as they had failed to identify some of the issues, we found regarding the fire doors and cleanliness of some equipment. The newly appointed management team had developed further processes to monitor the quality of the service and improve managerial oversight. At the time of this assessment these processes were still embedding and needed further time to ensure they were sustained. The manager demonstrated an understanding of the regulations and their responsibilities. For example, they had informed us about important events within the service. During the assessment period they attended their interview with CQC to become the Registered Manager which they successfully achieved.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff talked about the improvements in communication and teamwork since the new manager had started. They spoke positively about the changes and were confident they had resulted in positive outcomes for the people they supported. Staff felt supported by the provider and spoke about the opportunities available for their personal development. One staff member said, “You can always ask for more training if you think it would help. The manager encourages you to do it.” Another staff member said, “At my induction I was walked through everything. I learnt about the building, and I did my training. I spent time getting to know the residents. Now I’m in charge of inducting new staff. That makes me feel so good and shows I’ve learnt."

Prior to our assessment visit the provider had taken the opportunity to reflect on the leadership and governance of the home and additional support had been provided to support the newly appointed management team to help drive forward improvements and managerial oversight. However, systems and processes needed to be strengthened further to ensure audits were robust and effectively operated to drive forward improvements in the quality and safety of the service. Staff recorded incidents and accidents, and these were reviewed by the management team and action taken to prevent reoccurrence. Any lessons learnt were discussed in team meetings.