St Denis Lodge 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 assessment 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 provider had established a positive, person-centred culture that was inclusive and empowering. The management team and staff demonstrated a strong understanding of equality, diversity and human rights, and described how they prioritised delivering safe, high quality and compassionate care. The management team shaped this culture by actively engaging with staff, people using the service, their relatives and other key stakeholders. They genuinely welcomed feedback and evidenced the actions taken in response. People were involved in or consulted about their care.

There was a want to continue driving improvements within the home and an emphasis on this being a team effort.

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 management team worked to maintain a consistent management presence to ensure the service ran safely and effectively.

However, we received mixed feedback from staff on how accessible they found the management team to be. Some staff told us they felt supported and found the management team approachable. Whilst others told us they did not always feel supported and felt the management team were not always approachable.

Throughout our assessment, the management team was open about the improvements that still needed to be made and was motivated to learn and improve the quality of the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

A clear and accessible whistleblowing policy was in place. Although staff provided mixed feedback regarding the approachability of the management team, they told us they felt confident to speak up if they had a concern. Staff were assured any issues raised would be taken seriously and handled appropriately.

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 and leaders completed training in equality and diversity. The provider invested in the development of staff and worked hard to retain them. Many of the staff had worked at the service for a long time and told us they were supported well by their colleagues and enjoyed their job. Management ensured equality of opportunity and experience for the workforce within their place of work, and throughout their employment. For example, rotas were amended for those that needed to attend training or exams.

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. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Services we regulate have a statutory responsibility to notify CQC about certain events that occur in a service. Notifications were submitted, as required.

Auditing processes were in place to monitor the service. Daily observations were used to maintain consistency of care, while monthly and quarterly audits covered key areas such as care plans, medicines management, infection prevention, and health and safety. Findings were recorded and followed up on, ensuring any shortfalls were addressed promptly and effectively.

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 was transparent, collaborative and open with all relevant external stakeholders and agencies. Staff worked in partnership with key organisations to support care provision, service development and joined-up care and to improve people's experiences, health, and wellbeing. The provider established effective processes to ensure partnership working with people, relatives and health professionals was maintained.

We received positive feedback about working in partnership from all health and social care professionals who responded to our request. Comments from partners included, “During my interactions with staff I have found their care planning to be flexible to meet the needs of their residents both permanent and on respite. They have carried out requested changes in care approach and taken on board feedback”, “Communication between the care home staff and our team is effective, helping to ensure safe and coordinated systems of care, particularly when residents transition between services. This collaborative approach supports consistency, safety, and positive outcomes for residents”, and “I have always found them hardworking, respectful, and dignified of residents and very responsive to changing things to make improvements.”

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. They actively contributed to safe, effective practice and research.

The service demonstrated a commitment to continuous learning and improvement. Reflection, evaluation, and improvement were integral to how the provider developed and sustained person-centred care.

Learning was evident at all levels of the organisation. Staff were supported to review incidents and accidents regularly, identifying lessons learned and adapting practice to minimise the risk of recurrence. Outcomes from these reviews were discussed in team meetings with a read and sign pack in the staff room to ensure learning was shared and embedded across the service.