Amber Lodge Nursing 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.

This is the first assessment of this location under a new provider. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 62 (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 provider was in the process of implementing a dementia strategy that aimed to develop care approaches for people living with dementia. Staff training had been reviewed, and changes were being implemented to replace some areas of on-line training with in-person training with the aim of improving the quality of learning experience for staff. Electronic systems for auditing and staff management had recently been introduced and plans for electronic care plans and records were planned to be implemented in the next 2 months. Improvements to the care environment were on-going with further improvements planned.

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. Staff spoke highly of the leadership team and were confident in their ability to create a successful caring environment for people. Staff felt listened to and found leaders approachable. One staff member told us, “They sort issues straight away and there feels an improvement.” Another staff member said, “There have been very positive changes in management, everyone knows what to do and what role we are doing.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff knew the provider’s whistleblowing policy and felt confident to raise any concerns directly with leaders or knew what other organisations they could raise their concerns with.

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 felt valued and listened to by the leadership team.

The provider did not have fully embedded clear responsibilities, roles, systems of accountability or good governance. They did not always have a comprehensive overview on information about risk, performance and outcomes. Whilst the provider had introduced new audits and was working to action plans to address shortfalls, the audits were not yet fully effective. This was because not all the issues we found on this inspection had been identified by the provider. For example, of assessing, monitoring and mitigating risks in the environment and in relation to people’s health, safety and welfare.

Notifications had not always been submitted to The Care Quality Commission when required.Notifications are changes, events or incidents that providers must tell us about. They are important as they help to show the provider is working in a transparent and open way.

Records of people’s care were not always accurate, complete or made contemporaneously. This did not enable the provider’s systems to analyse events accurately.

The provider acted on the issues found on this inspection and incorporated any on-going actions into their longer-term improvement plans.

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. The provider worked with local health and social care professionals involved in people’s care and in the commissioning of the service. For example, we saw actions plans were followed in response to recent audits of infection, prevention and control.

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. The provider had reviewed its approach to staff training, governance and management and as a result had implemented improvements with other improvements scheduled. They incorporated people’s and staffs’ experiences into audit systems to help ensure the provider maintained oversight of their direct experience of living and working at Amber Lodge Nursing Home.