Franklyn Lodge 9 Grand Avenue

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

W

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.

The service was in breach of legal regulations in relation to good governance. This was because the provider did not have effective systems to assess, monitor the improve the quality of the service. They have also not made timely improvements at the service where these had been previously identified, so people always received safe and effective care

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While the provider had established a clear vision, strategy, and culture promoting transparency, equity, equality and human rights, observations and team meeting minutes indicate that these values were not yet fully embraced by all staff and consistently embedded across all care practices.

Observations and some documentation suggest while many staff members demonstrated a positive and collaborative approach, this was not consistent and did not always demonstrate a cohesive, inclusive and compassionate culture. For example, managers had not identified and worked to reduce restrictive practices to protect people’s rights.

Leaders had failed to ensure that autistic people and people with a learning disability lived ordinary lives like any other person. There was a lack of provider oversight to ensure people were supported to grow their independence and have access to activities that were meaningful to them. The service leaders and staff focused on ensuring people’s basic needs were met without supporting people to develop and grow.

The service had not identified, assessed or taken action to mitigate against the risks associated with a closed culture. Some staff referred to the care home as “the unit”, verbally and in written records, rather than a care home where people lived and called ‘home’. Leaders had not worked with people, their representatives and staff to build a culture that focused on enabling people to enjoy their lives.

Overall, the provider lacked a unified and value-driven culture with inconsistencies in compassion, communication, and staff engagement which may impact the quality and safety of care.

The provider had not always led the service effectively.

Although there was support for the registered manager and they were held in high regard by health and social care professionals, many of the concerns identified during this assessment related to leadership. A variety of systems and processes required a review to ensure they were sufficiently robust to ensure effective oversight of the quality of the service.

Leaders had not embedded a culture that enabled individually designed support, so people were able to live a good, ordinary life as part of their community. There was a lack of focus on how leaders could identify examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff.

The way the service was provided by leaders and care staff did not ensure that people led confident, inclusive and empowered lives, that fully reflected national guidance on the way people with a learning disability and autistic people should be cared for.

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

The registered manager and team leader were available within the service, and families confirmed when they had raised concerns they were delt with promptly. A relative told us, “We have mentioned minor things, and they pick it up straightaway.”

Reviews of people’s care plans were held every 6 months and relatives were invited. One relative told us, “They always call me, we work well as a team, we have review meetings, and I make it my business to attend.”

There was a whistle blowing policy in place. Staff were informed about this as part of their induction.

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.

Staff spoke highly of the management telling us they were open to listening, flexible and supportive. The manager always thanked staff for their hard work at team meetings.

The provider had an equality and diversity policy, and staff had completed equality, diversity and inclusion training.

The provider did not consistently demonstrate effective governance arrangements. They did not act on the best information about risk, performance and outcomes.

Quality review and governance systems had not been fully established. There were no effective quality assurance systems to review, monitor and improve care documentation, risk assessments or the outcomes people wanted to achieve. Auditing systems used did not identify shortfalls that we found at this inspection. For example, the infection control audit had not identified shortfalls in the standard of cleanliness in the service. Nor had the environmental checks identified the concerns we found with the quality of the premises.

Providers for existing services for people with learning disabilities and autistic people are expected to demonstrate how they are working towards meeting the requirements of ‘Right Support, Right Care, Right Culture’ (RSRCRC). There was no reflection and review of care practices on how these were being met within the restrictions of the environment and facilities.

This meant that the provider could not be assured that the quality of care people were receiving and their safety, were always being effectively maintained and promoted.

The provider did not always demonstrate their duty to collaborate and work in partnership, so services worked seamlessly for people. People were not always offered opportunities to attend community groups or activities to improve people’s emotional and social wellbeing.

Systems used to engage with people, communities and partners were not always effective to identify new or innovative ideas that could lead to better outcomes for people.

However, the registered manager ensured relevant information was shared with people’s relatives and external professionals when required.The manager and staff felt comfortable to access support of visiting health and social care professionals when needed.

Relatives told us they felt involved and consulted.

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

Processes to review and identify any learning and service improvements following incidents were not in place. Although some staff told us learning was discussed at staff meetings there was no audit trail of this happening. Incident and accident forms did not have a lesson learnt section to identify any learning so this could be shared.

There were lack of service audits and the only ones we saw covered medicines, health and safety and infection prevention and control. Despite those audits that were carried out to identify areas for improvement, we still found concerns with health and safety in relation to the environment and also in relation to infection prevention and control.

At the last inspection in August 2023 a beach of regulation in relation to good governance was identified and the service was rated requires improvement in well-led. At this inspection the provider had not made the necessary improvements and there was little to confirm whether the provider had implemented any innovations and good practice to care for and support people with a learning disability and autistic people.