The 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 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 remained 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 clear values and expectations for the provision of care and support for people. The registered manager’s personal values were in line with the provider’s values. The management team told us they expected everyone to work towards the same goals of safe, caring, person‑centred support. People’s relatives agreed with this. They said leaders communicated well and involved them in care planning. One relative told us, “I can tell when I’m being disregarded and I do not feel like that.”

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 and honesty. The registered manager was knowledgeable and passionate about the service. They told us they were keen to empower the staff team, and they wanted to develop and promote the service. Feedback from members of staff about leadership and management was mixed. We raised this with the provider and their response provided assurance an evidence-based approach to improving the service in line with organisational values was in place. The registered manager focused on maximising staff attendance for mandatory and role specific training. There was an awareness this had caused some challenges within the staff team, but a supportive and rewards-based approach had been developed to encourage increased participation.

The provider had systems in place so members of staff could speak up, however, they did not always feel they could speak up and their voice would be heard. The service had a whistleblowing policy which gave guidance to members of staff about who they could speak to should they have any concerns. Members of staff knew how to raise concerns and were able to provide feedback both anonymously and in person, however, some members of staff told us they did not feel confident using these systems would enable their voices to be heard. We raised these concerns with the provider and they told us they were aware of the concerns and they had put some additional arrangements in place intended to support speaking up and fairness. These included access to a ‘See Hear Speak Up’ phone line and information about how to speak a member of the provider’s senior management team directly. The provider also facilitated ‘listening sessions’ at the service which enabled members of staff to discuss any concerns directly with them. The new systems and processes to enable members of staff to speak up needed to be embedded and sustained throughout the service to support the on-going development and continuous improvement of culture of speaking up and listening.

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 and procedures supporting diversity and inclusion within the service. Members of staff were able to access support via the ‘Employee Assist’ program and had access to staff reward schemes. There were regular staff meetings held where members of staff could raise concerns, discuss issues, and share suggestions for improvement. Members of staff who did not attend the meetings in person had the opportunity to give their feedback to be included in the meeting.

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. Clear governance systems and processes were in place which enabled the management team and the provider to monitor and review the quality of care and outcomes for people. The management team carried out regular audits which covered areas including medication administration, infection control, fire safety, equipment and care plans. These checks and reviews helped the provider manage risks and supported a culture of continuous service improvement.

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. A member of staff told us, “We take advice from specialist nurses, psychiatrists, speech and language therapists and other members of the multi-disciplinary team (MDT) as appropriate." People were supported to access their interests outside the service. A member of staff said, “Most days people will go out into the local community and beyond. Medical appointments are in the diary and visits to and from family members are planned and documented in the diary and on [the electronic care planning system].”

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 registered manager participated in learning and peer support with colleagues and leaders across the provider’s group of services. The registered manager was keen to challenge previous ways of working to support continuous service improvement. They had taken the opportunity to seek out similar services with outstanding ratings and develop relationships to identify excellence in practice and new ideas to support improvement. The provider demonstrated a structured approach to workforce development through apprenticeship pathways at multiple levels, which supported progression from operational to leadership development.