Lyndhurst 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

There was an inclusive and positive culture of continuous learning and improvement. This was based on meeting the needs of the people using the service. Leaders proactively supported staff and collaborated with partners to improve the service and enhance the quality of care being delivered to ensure it was safe and person-centred.

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.

The management team were clear they wanted to continue to improve the service and outcomes for people both in their experiences and environment. The management told us, “A key priority was to have drivers available to take people out in the minibus and we achieved this and recently recruited several drivers. We are now looking at more community-based activities for people which align with their routines. Residents already go bowling, go to the cinema and play crazy golf and one of our residents will shortly restart carriage riding. But there is more out there, and one goal is to offer trampolining sessions at a time of the day that suits our people best. Our key priority overall is to do the best we can for our people by improving their life skills. And we are in the process of moving one gentleman into a supported living service.”

The provider and manager had kept up to date with local and national developments within health and social care and attended forums, training and signed up to reputable websites to access advice and guidance such as Skills for Care. Skills for Care supports adult social care employers to deliver what the people they support need, and what commissioners and regulators expect. Daily handovers meetings took place, and these were documented.

Staff told us they felt supported by the management team who they described as kind and responsive. The management team and staff demonstrated a genuine passion for people and in providing the best care possible. One staff member told us, “Working here is about supporting people to have the best life possible, making them smile, feeling like you’ve made a difference.” The management team told us, “The staff here really care and are honest; they have people’s best interests at heart.”

The management team led with integrity, openness and honesty to ensure care and support was delivered in line with people’s wishes and expectations. People and relatives told us that the management team had an open-door policy and made time to talk with them a priority. A relative told us, “The manager and the owner, are always available and will return calls, messages or emails even when they are on holiday.”

Staff confirmed they were invited to meetings and were encouraged to contribute. Staff meeting minutes evidenced that these took place four times a year. Staff were encouraged to voice their ideas for improvements and any concerns. Staff knew how to raise concerns with the provider or outside the organisation if they needed to, for example, with the local authority safeguarding team or CQC. All staff understood whistle-blowing and felt confident to do this if needed.

The provider had systems and processes in place to foster a positive culture where people felt they could speak up and have their voices heard. There was a Freedom to Speak Up policy in place and the Complaints process was available.

The provider told us they felt well supported in their role and utilised the assistance of human resources when required. The management team told us key achievements included staff retention and developing the caring, professional skill set of the staff. The manager told us, “We do the best we can for our people, improving their life skills, and are delighted we have one gentleman to the point where he can move into more independent living."

The provider had systems in place to ensure that there was an inclusive culture. Staff told us that the culture of the service was open, transparent and supportive, and they all worked together well as a team. The workforce was diverse, and support was in place for staff. Flexible working was in place to support staff who gave examples of how this had supported them in relation to childcare and health appointments. The manager told us, “I am supported so I can support my team.”

Staff told us they liked working at the service and the manager was supportive and approachable. Staff we spoke to were confident that they could discuss any concerns with the management team, and these would be acted on in both a timely and appropriate manner. Staff were aware of how to escalate concerns to senior management or outside of the organisation.

The provider had an audit programme in place and regular audits were undertaken by the management team. If audits identified any areas of concern, actions were identified and actioned. Learning actions required from the last inspection had been completed except for the development of epilepsy risk assessments to guide and support staff before, during and after seizure activity. People’s personal care records were stored securely including on laptops and applications on devices were password protected so that only staff who had been authorised to access the information could do so. Services providing health and social care to people are required to inform CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. The management team had missed submitting a notification to CQC in the event of a safeguarding referral they had raised with the local authority, however they took immediate action to rectify this.

People and relatives told us about the visits they received from other health care professionals. A person told us how excited they were to be visiting their friend at a local café and to be going home for the night.

The management team received peer support from provider forums such as Kent Care and SCIE (Social Care Institute for Excellence). Staff told us how they supported people with their health appointments as well as keeping in touch with their family and friends. All staff worked closely with visiting professionals and explained how they welcomed visitors. The manager told us, “We are always in contact with health care professionals, the local authority and with families. We email, take residents to meet families in the community and facilitate overnight stays. We have recently had a day out at Lego Land.”

A health care professional told us, “Lyndhurst House promote the quality of life of their residents and seek support from professionals appropriately.”

The provider had systems and processes in place to collaborate and work in partnership with health partners, social services and the local authority contracting teams. This enabled them to share information and learning with partners and collaborate for improvement.

The provider had systems and processes in place to continuously learn, improve and innovate the service. Surveys had been sent to gain feedback from people, relatives, staff and professionals. Complaints were discussed as a management team and viewed as a positive opportunity to improve the service. The service has a Complaints Policy in place. No complaints had been made in last 12 months. Learning had been embedded because of actions raised from the previous inspection. Specifically, the implementation of more robust protocols and procedures to enable staff to raise, document and escalate issues that related to the safeguarding of people in their care. The incident reporting forms had been reconfigured and a separate monitoring system has been designed to enable the Manager to be alerted to any potential safety issues relating to people living at the service.

Residents, and people acting for them, had been issued with information on the complaints procedure in a format they understood. The views of residents and families were captured by speaking with them, reviewing survey results, listening to suggestions made in person, via email or phone or from the closed social media page, and from feedback to staff at team meetings. A Monthly Provider report was generated by the manager to ensure that the provider was aware of the monitoring of the service and any issues that had arisen from the monitoring checks. Internal quality assurance audits took place monthly which addressed finances, aesthetics and staff and service user well-being. These audits were used to gain up to date quality assurance information to improve service provision. The contentment of the people using the service with the positive feedback from relatives and health care professionals, and the staff knowledge of people was evidence that residents were being listened to.