Dundoran Nursing and Residential 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 assessment 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.

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. The manager demonstrated an understanding of their responsibilities under duty of candour. Staff told us they felt the culture within the home had improved in recent months. One staff member told us, “There have been lots of positive changes since the new manager started. Much better communication with all staff. The management team are more visible and much more approachable."

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. A staff member told us, “The manager is really good and supportive. The office door is always open.” This was a view shared by people who lived in the home. One person told us, “The new manager is brilliant, very approachable and personable.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. A staff member told us, “Any problems I would be confident to raise with the care team leader or a nurse. I would also be more than happy to go straight to manager.” Systems were in place to ensure people who spoke up were supported and identity was protected.

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. Policies were in place to support this. Staff gave examples of how the provider had responded to helping staff through personal circumstances and challenges. The manager had recently reintroduced an ‘employee of the month’ scheme to recognise staff and demonstrate appreciation.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. Effective systems were in place to monitor and review the quality of care and experiences of people. Regular audits were completed and demonstrated a commitment to continuous learning and improving care. The manager understood their responsibility for notifying the CQC and other agencies of events which occurred within the service and accurate records were maintained.

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. Information contained within care plans demonstrated staff worked in partnership with other agencies. Partners we spoke with supported this and told us this had greatly improved in recent months. Comments included, “Staff work well with our team. They will contact us for advice and seem quite knowledgeable” and “The staff do engage with us. The clinical lead is very helpful and gives us all the information we need.”

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. A complaints policy was in place and information on how to make a complaint was clearly visible. People confirmed they knew how to raise a complaint and who they would complain to. The manager sought the views of people who lived at the home, family members/other visitors and staff, through regular meetings. Records were maintained of any actions taken.