Sandiacre Lodge

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 for this service. 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 governance at the service.

This service scored 54 (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 developed a shared vision and culture that reflected values of transparency, equity, equality, human rights, diversity and inclusion. The provider’s strategy emphasised meaningful engagement with people and an understanding of the challenges faced by individuals and the wider community. Both the provider and staff described a commitment to delivering a person‑centred service that empowered people and promoted positive outcomes.However, despite this stated direction, we found the culture was not consistently experienced in practice. Not all staff felt valued or supported in their roles. This affected morale and limited the service’s ability to fully embed its values across the workforce. These inconsistencies meant the provider’s intended culture was not always reflected in day‑to‑day practice or in the experiences of staff.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. The provider recognised that improvements were needed to strengthen the leadership of the service and had developed an action plan outlining how they intended to address these issues. This included proposed changes to systems and processes to improve governance, leadership and team cohesion. However, these improvements had not yet been fully embedded, and further work was required to ensure they were effective and consistently applied, to demonstrate sustained changes in the areas identified during our assessment.

We received mixed feedback from staff about how well they were supported to speak up and raise concerns. Some staff felt confident that any issues they raised would be addressed, while others told us their concerns were not always taken seriously. Our review of staff meeting minutes showed that, although staff had requested their rotas be provided in advance, this had not been actioned. The provider told us they had recognised this and had an improvement plan in place with the aim to strengthen communication in the staff team.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Some practices and decisions did not support a workplace where staff were respected or treated fairly. The provider did not always ensure that the hours staff were required to work were safe or manageable. Some staff were scheduled to work consecutive 12‑hour shifts during both the day and night. In addition, some staff were required to attend training immediately after completing a waking night shift.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.The provider had failed to ensure there were effective governance arrangements in place to ensure the service continually improved. Although a series of audits had been completed, these were not effective in identifying the concerns we found during the assessment. For example, while health and safety checks had taken place, they failed to identify the fire safety issues that we found. Audits also did not recognise the lack of guidance available to staff on supporting a person with their dietary needs, and the extended hours staff were working. In addition, staff did not receive their rota in advance, which had not been addressed through the provider’s oversight systems. These shortfalls demonstrated that governance processes were not sufficiently effective in ensuring safe and well‑managed care.

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. We saw evidence of effective collaboration with external partners, including appropriate information sharing and seeking specialist input to support improvements in people’s care. For example, the provider had engaged a positive behaviour support trainer, and staff told us this had been beneficial. They explained that the training had helped them develop more detailed care plans and strategies tailored to people’s individual needs.

The provider recognised that improvements were needed and had developed an action plan. The planned improvements needed to be embedded to demonstrate the changes required in the service. The provider had made improvements to the training offered to staff and recognised the positive impact this had. They told us how they planned to further develop this learning and embed it further into staff practice.