Boughton Lodge Care Home

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. There was a positive culture at the service now, where people living there and staff felt supported and happy. There was a newly registered manager who worked closely with staff and the provider to provide care. There were suitable governance systems now in place including a range of policies and procedures which reflected best practice and legislation. There were effective systems for monitoring and improving quality as well as learning and reflecting on feedback from stakeholders.

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.

People, their relatives and staff gave positive feedback about the culture and leadership of the home. Staff felt the management team were approachable, fair, and supportive. They were kept up to date, supported and felt involved in the service. We saw evidence that when concerns had been raised, the management team addressed these, and lessons were shared and acted on. The registered manager was open to ongoing learning and improvement. Progress against actions was monitored to ensure plans were achieved. The provider now had systems to monitor and improve standards and safety and action was taken when shortfalls or concerns were identified. Staff received training and understood equality, diversity and human rights principles. The provider was keen to ensure everyone felt included and valued in the organisation. People were supported by staff to take part in activities and pursue their interests. People were encouraged to maintain relationships that were important to them, and friends and family could visit at any time. There were well established links with other professionals which helped in providing good care provision and joined-up care. Staff and leaders promoted a positive culture and were committed to providing a good service to the people who lived at Boughton Lodge Care Home. The registered manager told us they felt the service was a happy, family orientated and transparent environment which they personally enjoyed working in. Regular team meetings, handovers, emails and supervision helped staff to feel involved in the service and kept updated about any risks or challenges. The provider, along with the registered manager now monitored and reviewed progress with improvements and plans at the service.

People, their relatives and staff were confident about the leadership of the home. Staff felt the management team were approachable, fair and supportive. The registered manager told us they received regular supervision, had meetings with peers and felt supported by the provider. The registered manager and provider both had a visible presence within the service, led by example and were available during our site visits. They had the skills, knowledge, experience and credibility to lead effectively and were open and honest during this assessment. The registered manager was knowledgeable and interested in wider issues such as the recent changes to the CQC methodology and the implementation of the Single Assessment Framework.

There was a positive culture where staff felt they could speak up and their voice would be heard. Staff felt confident that the new management team would address any concerns they had. We saw evidence when concerns had been raised, the management team investigated them sensitively, and lessons were acted on and shared. Staff had access to whistleblowing policies. The provider had systems to support them when identifying concerns or raising issues.

Boughton Lodge Care Home had a diverse workforce and staff told us they felt able to be themselves and did not fear discrimination. The registered manager was able to give several examples where they had needed to provide support regarding staff protected characteristics. Staff had access to equality and diversity policies and guidance, and reasonable adjustments could be made to meet specific needs such as caring responsibilities or religious obligations.

People and staff were now complimentary about the management team and the other staff working in the home. Staff understood their role and responsibilities. They told us they felt they managed to maintain a quality service because they had good working relationships with people, cared for them, wanted to keep them safe and provided person centred care. At the last inspection, we identified a breach of regulations relating to good governance. At that time, we found the provider and registered manager had failed to have all the systems required to assess, monitor and mitigate the risks relating to the health, safety and welfare of people, staff and visitors. At this assessment we found improvements had been made and the provider was no longer in breach of regulations. The provider had a robust quality monitoring system in place. Management staff at the home and the provider carried out audits which monitored the quality and safety of the service and devised action plans devised on their findings.

People were encouraged to maintain relationships with those who were important to them, and visitors were welcome in the home. People and their relatives told us staff worked closely with health professionals, community groups and local churches. This showed the staff team worked with others to provide a service which met the full range of people’s individual needs. Staff said there were good relationships with external stakeholders, and they appreciated that the district nurses and doctors who came to the service were familiar and consistent. We were given several examples of how the service supported people to access activities. This included setting up a lunch club, whereby people have the opportunity to select person centred subject matters where they have memory lane activities. Other agencies told us the service worked in partnership with them to achieve good outcomes for people. A GP visited weekly and there was regular contact with community nursing, safeguarding and social work staff. Professionals told us information was shared proactively to support good care provision and joined-up care. Boughton Lodge Care Home had a good level of partnership working with other agencies and professionals. Staff and leaders were open and transparent during this assessment process and engaged fully with the assessment team.

Staff were encouraged to raise concerns and suggestions and told us they felt listened to. Staff surveys and regular team meetings supported ongoing review and development. The new registered manager and the staff team were committed to providing the best outcomes for people. During the assessment the registered manager and provider acted promptly to address any suggested improvements. The provider had an overall development plan and specific action plans which provided evidence of ongoing learning, innovation and improvement. Impact and outcomes were measured with people, relatives, staff and other professionals as relevant. Improvements had become embedded since the last inspection.