Thornton Hall & 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 good. At this inspection the rating has remained the same.

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. Managers promoted a positive culture which was person-centred and inclusive of all. Managers and staff understood the visions and values of the service and reflected them in their day-to-day practice. Managers and staff focused on ensuring the possible outcomes for people were achieved. Their comments included, “We are here for the residents, it’s their home and everything should be the very best it can be for them all” and “We should not treat everyone the same they are all different.” Staff spoke positively about the manager describing them as approachable, fair and supportive. Equality and diversity was promoted for all.

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. There was no registered manager in post at the time of this assessment, the previous registered manager had stepped down from the role following a promotion to the senior management team. A manager had been appointed and they were in the process of applying to the CQC to become the registered manager. The manager had extensive knowledge and experience of working in the care sector including in a management role. People told us the manager spent time with them and were confident about sharing any worries they had with them. One person said, “[Manager] is lovely and often pops in, I would feel confident to raise any concerns if I needed to.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were confident about speaking up should they need to and felt any concerns they raised would be listened to and acted upon. Their comments included, “[Manager] is really approachable and does listen” and “[Manager] takes the time to talk when needed.” Managers held a one-to-one meeting with staff enabling them the opportunity to speak up in confidence. General staff meetings were also held and minutes taken and shared across the staff team. Staff meeting records evidenced the providers open-door policy was promoted and staff were encouraged to provide feedback, ideas and suggestions. The provider had a whistleblowing policy which staff knew about and had confidence in.

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. Staff told us they were treated fairly and felt valued and involved. Staff also told us there was good morale amongst the team at all levels, their comments included, “We all get on really well.” Reasonable adjustments were made to support staff where needed such as flexible working patterns. Policies covering equality, diversity, and human rights to support staff in the workplace were available.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Some audits and checks including IPC and medicines were not always effective in identifying and improving areas of risk. For example, outcomes of recent IPC audits and checks showed good standards of hygiene and cleanliness in kitchenettes and dining areas despite us observing them to be visibly unclean and unhygienic with a build-up of spillages and food debris. Medication audits had not identified the lack of records in place for the safe use of medicines prescribed to people to be given when required. However, other audits and checks completed were effective in identifying and bringing about improvements.

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. There was good partnership working with other services ensuring people received joined up care. We saw examples of effective partnership working and effective lines of communication with a range of external health and social care services such as local authority commissioning and safeguarding teams, community nursing teams, speech and language therapists (SALT) and dieticians. We saw examples of positive outcomes for people because of partnership working. For example, one person had reached a healthy weight through partnership working with dieticians.

The provider 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 contributed to safe, effective practice and research. We saw examples of good practice shared across the organisation as well as shared learning and reflections. Complaints were investigated and outcomes were used to improve the quality of the service. Managers were receptive of the feedback we gave during the site visit and acted immediately to make the required improvements. Following the site visit we were assured learning had taken place and more robust systems were put in place to ensure continuous improvements.