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 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 remained 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.

At our last assessment we found a breach of regulation relating to governance. At this assessment we found improvements had been made and were ongoing. However, we have found the provider remains in breach of regulation relating to governance.

This service scored 57 (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.

Staff induction records showed they were advised of the provider’s aims, values and ethos.Staff attended monthly staff meetings, where they were kept updated with any changes and guidance in the requirements of their role.

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 registered manager was supported by a deputy manager. They had a good understanding of people’s needs and how they were met. This included a good knowledge of dementia and/or people’s mental health conditions and how they affected people. However, we found a lack of sensory items and signage in the service to support people living with dementia. Leaders had not maintained oversight to ensure all the areas for improvement identified at this assessment had been independently identified and addressed.

We received mixed views from staff about if they felt they were listened to by management and actions taken. A staff member said, “The managers have good intentions and want the service to succeed. However, there are times when organization and communication could be stronger to help the team feel more supported.” Another told us, “The home encourages every staff member to bring out suggestions and voice out if there is something going wrong.”

We received mixed views from people using the service and relatives about the approach of the management team. A person told us they had been told the registered manager was too busy to speak with them. Although a relative said, “[Registered manager] is approachable kind and understanding, [deputy manager] is a delight.” Another relative told us, “[Registered manager] was extremely helpful and reassuring and so too was [deputy manager].”

People did not always feel they could speak up and that their voice would be heard.

There was a policy and procedure in place for speaking up and for whistleblowing. A staff member said I am aware of the whistleblowing policy and know how to use it if necessary.”

Staff told us they would report concerns, however, there were mixed views about how their comments would be addressed. A staff member said, “I feel comfortable approaching the management team to raise concerns, and they do listen to what I have to say. However, it takes a long time for them to actually take action and fix the issue.” Another staff member told us, “Management is open to suggestions on how to improve the service.”

There was a comment box in the service where staff could put any suggestions, anonymously if they wished.

The registered manager told us meetings were held for people using the service, but these were not always documented. Therefore, we could not be assured people’s views were sought and followed up on a regular basis. The registered manager told us the meetings would be documented going forward and sent us the minutes from a meeting held after our visits, where people commented on the service provided.

A member of the management team told us the service’s staff team were multicultural team, who got on with each other. This was confirmed by staff. However, we saw a lesson learned document, where staff were advised of ensuring they spoke English when at work, to ensure inclusiveness of their colleagues.

We received mixed views from people and relatives relating to the communication skills of the staff team. One person said, “Some of the staff do not speak proper English.” Another person told us, “Language and understanding some of the staff can be a problem, I asked for my backside to be washed and the carer said that [they] had done it, but [they] had done my back.” A relative said they had raised a concern and were not assured the staff member understood what they had said. We also received feedback that the staff interacted with people effectively. The registered manager told us staff’s language skills were assessed at interview and support provided where required.

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.

A range of checks and audits were in place including medicines, care plans, equipment, mattresses and medicines. These were sent to the provider’s directors when completed, including actions to be taken to address any shortfalls identified. The provider undertook a quarterly report on the findings of the audits and monitoring systems. However, although some of the shortfalls identified during this assessment had been identified by the management and a plan in place for addressing them. They had not independently identified and addressed all of them, this included shortfalls with recording in people’s daily notes and care plans, the organisation of meal times, dual recording of creams and repositioning, and prescribed shampoo not being used in line with guidance.

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 management team told us they worked in partnership with other professionals involved in people’s care. This was confirmed in records reviewed and feedback received from health and social care professionals.

The registered manager told us how they had worked alongside the local authority relating to funding.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

There were action plans in place to improve the service with timescales for improvement. However, the action plans did not include all the shortfalls identified at this assessment. We saw the service was in need of refurbishment and decoration, including in people’s rooms, for which there was a programme of redecoration ongoing, since concerns raised at our last assessment. New chairs had been purchased to replace the damaged chairs noted at our last assessment. Whilst we noted how the need for an update in the décor of the environment did not demonstrate care was taken to ensure people lived in a home where they were valued. We received feedback from some relatives where they had identified this but also felt the care provided was more important. A relative said, “Obviously anyone can see that the interior and exterior of the home is probably in need of some decoration, but personally it is more important to be (and I believe my [family member]) that the care is attentive and kind, rather than everything being gleaming new.” Another relative told us, “We are impressed by the care, it is a bit shabby. Few things need doing up like painting, [previous services] both posh care homes, all about the flowers and reception area, but here the money goes on care.” Another relative said, “Recently there has been a bit of decoration and some new chairs, which were definitely needed. Like most places it could do with a little updating.”

There was a bathroom which was out of order and the registered manager told us there were plans for this room to be refurbished.