Lutterworth Country House 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

We looked at 2 quality statements under this domain: Capable, compassionate and inclusive leaders; and Governance, management and sustainability. The registered manager was approachable, listened to staff, and acted to address any shortfalls at the service. They had already made improvements to staffing levels and deployment. They had identified that some care plans/risk assessments needed reviewing and updating, and this work was in progress. Staff said the registered manager had had a positive effect on the service and as a result morale was good and people were receiving better quality care and support. The service’s audit showed improvement in most areas, although an infection prevention and control (IPC) issue had not been identified. However, this was promptly addressed when we brought it to the attention of the registered manager and regional director.

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.

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 told us the registered manager was approachable and listened to them. Most said morale at the service was good and the culture open and caring. A staff member said, “People [using the service] are confident in saying things to us and I help them where I can. I think people can tell us if they are unhappy.” All the staff we spoke with said the registered manager had improved the service, deploying staff more effectively, addressing maintenance issues, and ensuring there were good stocks of personal care items for people. The registered manager was experienced and knowledgeable and understood what needed to be done to improve the service. They worked closely with the provider’s regional director to address issues and priorities and ensure they had the resources they needed to provide good quality care. For example, they had identified that paperwork needed further improvement, and staff needed more in-depth dementia training, and were working with the provider to ensure these areas were addressed.

The registered manager worked flexibly at the service, so they were able to spend time with staff on their different shifts, including the night staff. This enabled all staff to feel connected to management and have to opportunity to discuss any concerns or issues with the registered manager. The registered manager carried out ‘spot checks’ to ensure staff were providing good quality care that embodied the culture and values of the service. Following these checks the registered manager made changes to the staff team and worked with individual staff members to improve their practice and the way they communicated with people.

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.

The registered manager said work was ongoing to update and review all care plans and risk assessments to ensure people’s current needs and risks were reflected in documentation. They said some were outstanding, but these had been identified and were being addressed as a priority. Staff were involved in these reviews and told us how care plans and risk assessments were improving as a result. The registered manager said they used staff supervisions, appraisals, training, and spot checks to address staff performance issues at the service. This led to improvements in staff members’ understanding of their roles and responsibilities, better communication with people, and a reduction in falls. Staff said the registered manager encouraged them to raise any concerns they had about the quality of care and support at the service.

Managers followed the provider’s audit schedule to ensure the service was running safely and effectively. Records confirmed audits were completed as planned. Where actions were identified these were recorded and addressed. However, the service’s infection prevention and control (IPC) audit had not identified the fly issue at the service as an IPC risk. Consequently, this matter was not fully resolved until our visits to the service. This showed the providers IPC policies and procedures were not always effective. The audit summary for the three months prior to our inspection visits showed improvement in most areas. The service’s dignity audit included interviews with seven people all of whom said they were treated with respect and involved in decisions about their care. Most people said there was a lack of activities. This was being addressed by the registered manager who was in the process of employing a new activities co-ordinator. Notifications of accidents/incidents were consistently submitted to external organisations as required. Records were kept securely as required by the General Data Protection Regulation (GDPR).

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.

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