Sobell Lodge - Care Home Physical 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 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 and management of the service.

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 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.

Most people and their relatives told us the staff team was caring. Staff understood the organisation’s stated vision and values and told us they aimed to deliver a service that met people’s needs. A staff member said, “Yes, residents are 100% safe. The team are incredibly caring. The care team work so hard to keep the residents safe. Residents are always the main priority.” We saw that the organisation’s values were displayed and shared with staff during their induction.

However, staff reported that instability in management and ongoing staffing pressures made it difficult to consistently deliver care that met people’s needs. A staff member said, “We have meetings but not much get actioned. There is no one that takes responsibility and accountability for anything. We have to keep going over the same thing rather than things being actioned or being done. It feels like it takes forever to get things sorted out. I think it is mainly because we do not have a consistent manager. A new manager starts something and then they leave and it’s not passed on and then you have to start the process all over again. The issues which are raised are to do with house needs and residents which need to be actioned.”

We found the culture did not always support open reporting of concerns. Staff were not consistently reporting incidents, and when things went wrong, information was not always escalated appropriately. Staff also described inconsistency in how actions were taken once concerns were raised.

A staff member told us, “At the moment, we don’t have a stable manager, which has made things difficult. We share the information and hope it will be addressed, but you often have to chase or find out yourself if any actions have been taken regarding the concerns you raised.”

The manager told us they had recently introduced regular staff meetings to provide a space for raising concerns, reporting incidents, sharing outcomes, and reflecting on learning. Staff confirmed these meetings had begun and told us they found them helpful.

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.

Relatives expressed mixed views about leadership visibility and capability. A relative told us, “I think the people above are not visible and we don't know them or have confidence in them.” Another relative said, “The interim manager is approachable and is supportive with my personal circumstances.” A further relative commented, “The new manager and deputy are making progress. We are afraid for when the manager goes.”

Staff consistently raised concerns about instability in management. A staff member told us, “We have not had a stable manager for a long time. It’s been very frustrating; the service managers come in and have their ideas and then they start changing things and then they leave and then someone else comes in.”

Another staff member said, “There hasn’t been a stable manager for a while. The deputy manager is doing their best and stepping in but it is hard doing everything.”

This lack of consistent leadership had affected communication, oversight and continuity. People, relatives and staff described uncertainty and a lack of confidence in the leadership structure, which impacted the service’s ability to implement sustained improvements.

The provider had a condition on its registration requiring a registered manager to be in post. At the time of our inspection, the provider was not meeting this condition, as there was no registered manager in place. The service had been without a registered manager for over 180 days. An interim manager was available during our visit providing operational oversight; however, they informed us that they were due to leave the service the week following our visit, creating ongoing instability in leadership. To mitigate the absence of a permanent manager, the provider had deployed a clinical lead to be based at the service. The clinical lead was supporting the deputy manager, who had stepped up to oversee the day‑to‑day running of the service. While this arrangement provided some managerial support, it did not ensure the service had the consistent, suitably qualified, and registered leadership required to meet regulatory expectations.

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

Staff understood their right to raise concerns and were aware of the mechanisms available to do so. Staff we spoke with expressed confidence in speaking up. A staff member told us, “We have a full whistleblowing policy with named contacts and email addresses, so concerns can be raised anonymously if needed, and we receive full support for whistleblowing.” Another staff member commented, “Yes, we have a Human Resources department, and we can also report concerns anonymously via an online portal.”

We saw information displayed in the home, including posters outlining how to raise concerns, which supported openness, transparency and a culture were speaking up was encouraged and understood.

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. They took steps to improve equality and equity for staff and supported individuals to feel respected and able to carry out their roles effectively.

A staff member told us, “I feel fully supported in my role with the equipment and adaptations I need. The service is flexible with my needs.” This ensured the work environment enabled staff to continue in their roles. Another staff member shared mixed feedback, saying, “Equality and diversity should be promoted more. I think staff would also benefit from equality and diversity training. In the past, staff were not always aware of their behaviours and how it affects others. We have the equality and diversity training once a year but would benefit from face-to-face training so people can understand and learn more.” This indicated work was ongoing to ensure all staff consistently experienced an inclusive culture. We noted the staff team was mixed and diverse and we observed open communication and teamwork. The manager told us they planned events and celebrations to promote diversity in the workplace.

Staff were given flexibility to practise their faith. For example, during Ramadan, shift patterns and working arrangements were adapted to support those who were fasting. Staff were also supported to swap shifts or adjust their working patterns to meet personal or family commitments.

The provider supported some career development through training, coaching and opportunities for progression. A staff member told us how they had been supported to develop and progress in their role, reflecting a culture that recognised and invested in staff potential.

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.

During our inspection, we identified several shortfalls indicating weaknesses in governance oversight. Care plans were not consistently updated and often lacked the level of detail required for staff to support people safely and appropriately. Care records were not always easily accessible, making it difficult for staff to obtain necessary information, particularly during busy periods or when agency staff were on shift.

Monitoring records were not always updated. People’s food and fluid charts were not completed to show how much fluid they were having were not. Incidents and accidents were not always recorded, and concerns and incidents were not always reported through the correct processes. Systems for monitoring complaints were ineffective, as records of complaints were not being maintained.

Some audits were completed such as medicine audits and health and safety checks were completed. However, we found that there was outstanding recommendation from a fire risk assessment since 2024. The assessor had recommended the development of a document clearly describing how the fire alarm system interfaces with other building systems, services and the intended operational effects as originally designed and approved. When we requested this document, or confirmation that it had been completed, the service was unable to provide either.

The interim manager had identified most of the issues we found during the inspection. They had developed an improvement plan, which they shared with us, and work was underway to implement required improvements. However, these changes were not yet embedded at the time of our visit. The provider had also deployed senior managers to audit the service, and they too had identified many of the same concerns. As part of their response, the provider had purchased additional equipment to support the safe evacuation of people in an emergency.

These findings showed that the quality of the service needed improvement and the governance systems and management of the service needed strengthening. The provider recognised this and had started putting resources in place to enable this.

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 healthcare professional told us that staff were now collaborating more effectively and working more closely with them. They explained that this had not always been the case, but that practice had improved.

Staff liaised regularly with external agencies and professionals, and we saw evidence of joint working to support people’s wellbeing and meet their changing needs.

The provider had developed strong links within the local community. People were supported to attend church, and a church group visited weekly for those who preferred to take part at home. The service also had established relationships with local schools and community centres, enabling a variety of intergenerational and social activities.

Community organisations visited the home throughout the year. For example, Morris dancers attended twice annually, providing entertainment and cultural engagement for people living in the home.

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.

The provider did not always demonstrate a strong focus on continuous learning, innovation or improvement across the organisation. Systems and leadership oversight did not consistently encourage creative or effective ways of delivering equality of experience, outcomes or quality of life for people. The provider did not always actively contribute to safe and effective practice or support the development of evidence‑based approaches.

Staff told us the paper‑based record system made accessing information difficult and time‑consuming. This hindered the ability to learn from information, review risk effectively and support improvements in care. Staff reported that finding key information in care records was challenging, which contributed to inconsistent care delivery.

The service had been without a registered manager for an extended period, and there had been no stability in the managerial structure. This lack of consistent leadership had a significant impact on the quality of the service and the provider’s ability to drive sustained improvement.

Staff training did not always reflect people’s specific needs. For example, staff had not received communication training to enable them to communicate more effectively with people who required alternative or adapted methods of communication. This limited staff’s ability to support people consistently or meaningfully engage them in and everyday life.

These issues demonstrated that the provider had not embedded a culture of continuous improvement or ensured systems were in place to support learning, innovation and high‑quality, person‑centred care.