Archived: Shore Lodge - Care Home Learning Disabilities

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 inadequate. 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 good governance.

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.The management team were clear they wanted to improve the service and outcomes for people both in their experiences and the environment. However, we found there were delays and resistance from senior managers to provide information in a timely manner through the assessment process. Some information we requested was not shared with us. The management team had worked hard with staff since the last inspection to improve the culture of the service. Staff reported improvements and told us they felt empowered to raise any concerns or make suggestions. Staff comments included, “It is definitely better at work, it is getting better and better every day” and “So far I have found [manager] supportive and willing to listen.”

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. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. Since the last inspection the previous registered manager had left. The provider had not alerted CQC as to who was managing the service. At this assessment we found there was a new manager in post. They had not yet applied to register with CQC. The management team knew people well and were passionate about making sure people received good quality care. They were supported by regional managers and the service improvement manager. The management team were present at the service regularly and undertook checks and audits.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Complaints processes were available. Staff confirmed they were invited to meetings and encouraged to contribute. Staff were encouraged to voice their ideas for improvements and any concerns. Staff knew how to raise concerns with the provider or outside organisations if they needed to. A staff member said, “I know about whistleblowing. We have a number to call.” Another staff member told us they would have no concerns raising concerns with any of the management team. They said the management team are, “More open now and concerns and ideas are 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. Actions to address areas of concern about the previous culture had been taken by the provider and management team and this was being reviewed regularly to ensure it was embedded. The provider cared about and promoted the wellbeing of their staff. The management team told us that staff are well supported with staff care packages. These included access to a nationally recognised discount scheme for health and care workers, employee assistance programme and a flexible working policy. A staff member said, “The working environment has improved massively, staff are responsible and accountable."

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Since our last inspection the provider has been auditing and checking the service. There were monthly audits completed by the area manager and regular audits by the provider's quality and compliance team, the manager and deputy. Although these processes were in place, they were still not robust enough to highlight and manage shortfalls in the service. For example, the audits had not detected all the issues at this assessment regarding management of risk, medicines, legionella risk, consent, person centred care and food and fluid records, despite these areas being reviewed as part of the audits undertaken. A personnel file audit had been undertaken. This audit had picked up there were missing photos on staff files for 3 staff and gaps in employment which had not been explained for 5 staff. The provider's audit/action plan recorded a date of expected compliance of 30 December 2024. This had not been achieved as we also found gaps in employment which had not been explored. The management team had also carried out audits and checks of practice out of hours which included weekends. We were not assured that all incidents were reported to CQC, for example, a serious injury to a person which had occurred on 24 November 2024 had not been reported.

The rating of the service was not on display on the provider’s website when searching the website for care homes. This meant relatives and the public did not have up to date information about the service. A relative told us, “I had not been kept informed about last year’s inspection and the rating. They did not tell me about that at all.” The rating was on display at the service for people and visitors. We received mixed feedback from staff about how supportive the management and provider was. A staff member said, “I am happy coming to work, it is like a different place. I get lots of support.” Another staff member told us, “I think the improvements made are not as much as they could have been given the amount of managers who have been coming here, particularly just after the inspection, but they are more office based, and don’t observe as much as they should as some staff not as good as others.”

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. The manager told us they were working closely with the community and trying to expand opportunities for people. All staff worked with visiting health and social care professionals. Staff explained how they welcomed visitors. We observed some people were supported to get out into the community to access shops and fresh air and some activities. However, we observed there was not much structure around this, particularly for autistic people. Activity records did not evidence that activities to meet people’s needs, particularly their sensory needs, were taking place in the service or in the community. Some staff told us people were not going to day services and some staff told us they were going. One of the local authorities who commissions services for people told us they had seen improvements in the last year. They said, ‘During our visit staff explained that they were going for a drive with some of the residents, which included going to Bluewater shopping centre for food. Residents were listening to music of their choice, staff were with them and engaging, residents were supported to access the garden for a vape if they chose to do so, they were then going out into the community, another resident was being supported by staff to check her money allowance and was then also going out.’

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. They did not always actively contribute to safe, effective practice and research.Since our last inspection there had been improvements at the service and these were in the process of being embedded. However, further improvements were required to ensure lessons were learned. A relative told us that the provider had met with relatives following the last inspection to talk about the report and what actions they were taking to address the serious shortfalls at the inspection. The relative said, “They had a lot of the top Leonard Cheshire managers come down, they had a big meeting. There were only 2 families that came. They told us they would make improvements and do everything in their power to keep the service open.” Some relatives were unaware of the serious issues at the last inspection. There was a lack of learning and critical review of incidents that had taken place at the service and lessons had not been learned. Systems, processes and practice had not been reviewed and amended to ensure people received safer, better quality care. However, we did find that there had been discussions at the managers quality meeting which had taken place in November 2024. This meeting showed there had been some organisational learning regarding food hygiene, employment checks, CQC updates, guidance and training relating to MCA and Dols for managers and links to CQC training and webinars as well as links to safeguarding referral forms.