Heathgrove Lodge Care Home

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 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 64 (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 always have a shared vision, strategy and culture. There was a culture based on transparency and equity, but people’s diverse needs were not always supported. They did not always understand the challenges and needs of all people and their communities.

There was a positive open culture at the home. The staff and new manager all contributed to this. Staff wanted to help people and do their best to make life comfortable for them. However, there were shortfalls regarding the social provision on offer which the new manager had also identified. There were also cultural and diverse shortfalls, the provider and manager were open to this feedback, during the assessment period they started to make some plans to work on these areas which we had identified. But it was not their own audits which identified and resolved these shortfalls, but our assessment.

The provider had 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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff spoke well of the integrity of the new manager. Incidents and accidents were quickly reviewed to see what interventions were needed. These were also checked by the provider. The new manager spoke openly with us and the provider about the work they wanted to do to make the service more inclusive and person centred following our feedback. We also found from spending time at the home, speaking with people and relatives, staff and professionals, there was a person centred culture at the home which would support these improvements.

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

Staff were clear they could speak up and tell the new manager about any concerns and suggestions they had to make improvements. They valued how the new manager had already demonstrated this culture, which was present under previous managers they said, despite only being at the home 2 months. People and relatives also felt confident to raise issues.

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 staff said they had stayed with the provider because they felt supported and secure with them, some of these were from diverse backgrounds. Some gave examples of the opportunities which they had taken regarding higher training, others knew it was on offer if they wanted to do this.

The provider did not always have effective roles and systems of good governance. They did not always act on the best information about risk and outcomes.

There were some themes and areas which the provider and manager had not identified and resolved when they assessed the quality of the care provided. We found some shortfalls in IPC, aspects of dignified care, the social provision at the home, some risk management, end of life planning, best interests processes, one PRN medicine, and not exploring people’s cultural, diverse needs, and their interests and passions before they moved to the home and developed dementia. The providers audits also did not always capture how they reached their conclusions of compliance; they did not always show the audit had been thorough. The providers audits failed to identify and rectify these issues.

The service did not have a registered manager in post. However, the provider told us the new manager intended to make an application to register with the CQC.

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.

We saw examples of staff and the manager working well with health professionals, when people were unwell. The provider told us they had already made changes with how they audited their other care homes following our feedback about this 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 care for all people.

There was a positive culture of the manager and provider being open to feedback and suggestions. They confirmed to us some work had started and some work had been completed in the areas where there were shortfalls. However, the manager and provider audits were not robust enough to identify the issues we found and make the appropriate changes and improvements. In relation to providing a person centred care experience to some groups of people especially from a diverse ethnic heritage, the provider had not been curious enough to check staff and managers were meeting the cultural needs which were important to all these people.