Courtland 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.

At our last assessment we rated this key question good. At this assessment the rating has changed to 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 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.

Most staff gave positive feedback about working at the service. A staff member said, “[We are a] great team, we work together. My line manager is brilliant; [they are] hands on.” Another staff member said, “I feel we have a very good unit manager. Feel well supported. I’d go to [managers] if I did, no problem.”

Staff and managers engaged well with relatives. A relative said, “The manager/office team are always very happy to listen, and they are polite and helpful.” Another relative said, “They do listen to you and they get involved.”

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 but this had not always been done effectively. We had concerns about the management of some risks to people.

People and their relatives spoke positively about the registered manager. A relative told us, “The manager is approachable.” A person said, “Yes, I do know the Manager here…[they] listen and deal with matters.” Another person told us, “I do know the Manager here. [Manager] does come round quite regularly.”However, we were also told, “I have found the manager and deputy manager, pleasant but not proactive enough and not demonstrating strong management skills.”

Another professional told us: “The manager has a good relationship with my team lead responsible for this care home and they engage well in meetings when there are concerns or issues to be discussed.”

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

The provider had a whistle blowing policy and staff told us they felt able to speak up. Some staff said they felt able to speak to their line managers but not more senior leaders and some said they knew who to raise concerns with but felt action was not always taken. However, the majority of staff told us they felt listened to.

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.

The provider had policies to support fair treatment of staff. Staff gave mostly positive feedback about support from managers and colleagues.

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, or share this securely with others when appropriate.

The provider’s processes to monitor the quality and safety of the service were not always effective. Their audits had not identified the issues we found. For example, while the fluid monitoring audit recorded which individuals missed their hydration targets and why, it failed to notice staff were not consistently offering people their daily targets. Whilst prompt action was taken in response to issues we found with medicines, their processes had not identified these.

People’s records were not always updated throughout to reflect changes in needs and information in risk assessments contradicted with information in care plans. For example, a person’s continence risk assessment stated they required support from 1 staff member, but their care plan said 2.

Staff completed incident reports which included what happened and initial action taken. We discussed incidents with the registered manager who described themes from incidents and gave examples of action taken and how they share these with staff. However, the incident reports we reviewed lacked evidence of action taken. Therefore, we were not assured learning was always identified to help prevent them happening again.

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.

People had access to other professionals as required. A person told us, “The Health professionals come round but I haven’t needed to see them yet. It is assuring to know there is a GP, 2 I think, who come round regularly.”

A professional told us, “The service work collaboratively with us and any concerns that we raise are addressed promptly.”

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 provider was responsive to the concerns we raised. For example, the issues we identified with medicines at our first visit had been actioned before our second visit.

Following the incident which occurred prior to our visit, some actions had been taken to reduce the risk to people. The registered manager was focused on the importance of learning from what happened and told us, “I hope it prevents it from happening somewhere else…I feel this will bring lots of awareness.”