Jericho 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 still 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 regulations in relation to their quality monitoring systems which were not always operated effectively. This was identified as an issue at the providers last assessment. At this assessment we found not enough improvement had been made because the providers governance systems were still not always picking up and/or resolving issues we identified during their inspection. This included fire resistant doors not always closing into their frames properly when released and the potential risks posed to people with uncovered radiators in their bedrooms not being risk assessed.

This represented a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the evidence category findings below.

This service scored 61 (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 were supported by their line managers to deliver consistently safe, person-centred care to people in line with the provider’s vision and values for the service. A member of staff told us, “We work well together and have a good team spirit.” Managers told us they routinely used individual and group meetings to remind staff about the provider’s underlying core values and principles.

Not all leaders understood the context in which the service delivered care and support. Leaders did not always have the local knowledge and experience to lead effectively.

The service has not had a registered manager in post for the last 6 months[. This lack of a suitably experienced and skilled manager in day-to-day charge of the care home has adversely affected the consistency of service delivery including, the effectiveness of their governance systems and how they maintained and could access records.

We discussed this issue with a regional manager who was overseeing the service at the time of our inspection. They acknowledged the service needed a suitably experienced and qualified registered manager in day-to-day charge of the service again to ensure care and supported was consistently delivered. They told us they were in the process of actively recruiting a new manager for the service and hoped to have a suitably fit and competent person in post by August 2025. The regional manager provided us with additional evidence after our onsite inspection. They confirmed in writing that a suitably experienced and qualified manager who helps run one of the providers other care homes in the area was now in temporary day-to-day charge of Jericho Lodge and will remain in post there until a new permanent manager is appointed.

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

The care home had an open and transparent culture where people living there, relatives, external health and social care professionals and staff felt confident about speaking up and raising any concerns they might have without fear. Typical comments included, “I do feel comfortable talking to staff here. They do listen to us”, “The managers and staff are all very approachable and friendly and they do try and involve my family and listen to what we have to say about my [family members] experiences of living at Jericho Lodge” and “I feel one hundred percent confident about being free to speak up and share my views with my managers about what it’s like working here”. The provider used a range of methods to gather people’s views about their experiences of living, visiting or working at the care home including, what the service did well and what they might do better. This included regular individual and group meetings with people and satisfaction surveys. People told us they felt comfortable raising concerns with the managers and felt 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.

Staff were positive about the leadership approach of the management team who they said treated them fairly. Staff told us there views were always respected and listened to by the managers and they felt valued members of the team.

Managers understood the importance of having a fair and inclusive workplace for all staff to work in. Staff were provided support through relevant training and supervision to inform their knowledge and understanding of equality, inclusivity and fairness in the workplace.

The service 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.

At this assessment we found the provider had not improved how they operated their governance systems and maintained records they were legally obliged to keep, as recommended at their previous inspection. This was because the provider was still failing to pick up and/or take appropriate and timely action to address issues of concern we identified at the inspection. This included faulty fire-resistance doors not being repaired in a timely manner and potential risks people might face were not always being properly identified and assessed, to prevent or mitigate them.

In addition, the quality of information recorded and maintained in people’s records, and records relating to the management of the service was not always sufficiently detailed, up to date or accurate. For example, the managers were not always able to immediately access health and safety certificates to demonstrate relevant professionals routinely checked the safety of the services gas, electrical and water systems. Furthermore, no information and guidance about how people could raise an informal concern or formal complaint was displayed in the care home, contrary to recognised best practice and the providers complaints policy.

We discussed these issues with the managers at the time of our inspection who acknowledged these failures. They took appropriate and prompt action by the end of our assessment. This included ensuring information about how people who might want to raise a concern or complaint was easily accessible within the service. We were also provided with up to date certificates that showed the services gas, electrical and water systems had all been recently checked and deemed safe by the relevant external professionals.[MP3][LW4]

The managers and staff understood their responsibilities in relation to regulatory requirements around notifiable incidents. Our records indicated they continued to notify the CQC in a timely manner about any incidents and events they were legally required to.

We saw the service's previous CQC inspection report, which was clearly displayed in the care home and was easy to access on the provider's website. The display of the ratings is a legal requirement, to inform people, those seeking information about the service and visitors of our judgments.

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.

Managers and staff told us they worked closely with various external health and social care professionals and bodies who they regularly consulted and welcomed their views and advice. One member of staff told us, “We have very good working relationships with various community based health and social care professionals, including psychiatric nurses, social workers, GPs, speech and language therapists, teachers and the police.” External care professionals were equally positive about their working relationship with the provider. One remarked, “The manager I met does listen and accepts advice with give them about our client’s needs,” while another added, “The managers are responsive and willing to accept advice from us and communication remains good with them.”

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The service did not always have a proactive culture of continuous learning and improvement. This was because the service had not had a stable registered manager in day-to-day charge of the care home for the last 6 months who would be able to focus on continuous learning and improvement.

We found opportunities to continuously learn lessons and improve the service were still being missed. For example, the provider had failed to improve how they kept records. This included records relating to assessing and managing risks people living in the care home might face and detecting and mitigating potential health and safety risks posed by the services environment.The providers established governance systems and audits were also still not being effectively operated to ensure they always identified and addressed the aforementioned issues in a timely manner, despite this being highlighted as an issue at their last CQC inspection.

The negative comments described above notwithstanding managers told us all the audits and checks the provider conducted were routinely analysed to identify performance shortfalls and learn lessons, so the service could improve. The provider had developed an action plan in response to all the issues they identified during their last audit which they were in the process of implementing.