Saxon Lodge Residential Home Limited

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 inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. The culture within the service was not open and transparent.

The provider had a vision statement for the service which included, ‘To provide a caring, safe, and welcoming home where older people and those living with dementia are empowered to live with dignity, respect, and the highest possible quality of life. We are committed to delivering exceptional person-centred care that promotes wellbeing, independence, and meaningful relationships while giving families confidence and peace of mind.’ The provider’s vision statement had not been discussed at staff meetings, and the registered manager had not acted to ensure the quality of the service provided supported the vision statement.

The culture within the service did not support people’s dignity or ensure people had the highest quality of life. Relatives were clear in their comments to inspectors, at meetings and in the quality assurance surveys, they were not confident in how the service supported their family members.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. The registered manager, who was also the provider, was not a regular presence at the service. Relatives told us they rarely saw the registered manager, and the registered manager had not attended meetings to understand their concerns. There was a deputy manager in post, who was in day to day charge. Relatives told us they had witnessed staff including the management team swearing in front of people, arguing amongst themselves and had experienced staff answering them back. Relatives told us they had reported these incidents, but they had continued.

The culture within the service was not open and transparent and the management team and staff could be defensive. For example, a visitor had raised a concern about an incident at the weekend, the deputy manager had investigated and spoken to staff. The investigation report showed staff had stated the incident had not happened and the visitor was racist. The action plan was to deliver training on cultural barriers; there had been no investigation into the concerns about poor practice or identified if improvements were needed to staff practice. The provider had not acted to drive improvement, promote a positive culture and address staff behaviour. There was a risk shortfall would continue unchallenged.

The registered manager had not always acted with integrity. Relatives told us, correspondence from the registered manager had not been professional and had not been supportive when circumstances changed to find an alternative placement.

People did not always feel they could speak up and that their voice would be heard. Relatives told us they raised concerns with staff when they visited the service, but they did not see any changes. For example, a relative told us, staff offered their family member a fried egg every Friday as they did not like fish. The relative told staff constantly their family member did not like fried eggs either, staff had not offered any other alternative and the person continued to be offered food they did not like.

Staff told us they felt they could raise concerns with the management team; however, they could not give any examples of when they had done this, and the actions taken.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. People were supported by staff from different countries and cultures. The registered manager had provided them with information about how the British culture may differ from theirs. The registered manager had identified some cultural divides within the staff group but had not been proactive in addressing this to help both staff and people to understand and celebrate all the different cultures.

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. The systems in place to audit and monitor had not been effective in addressing shortfalls within the service. The management team completed audits on areas such as medicines and care plans. The registered manager had identified people’s care plans needed to be more person centred; they had requested the care plans were reviewed by the deputy manager and relationship manager but had not provided guidance to ensure the care plans improved. The deputy manager had also completed care plan audits and had not identified the shortfalls. The shortfalls continued at the time of the inspection even though the care plans had been updated.

Staff completed monthly medicine audits, they had not identified the shortfalls found at this inspection. A medicines audit had been completed by an external pharmacist, the registered manager had not acted to rectify the shortfalls found and they continued.The provider had not monitored the quality of the records maintained by staff around incidents. Staff, including the management team, had not always completed accurate and contemporaneous records when incidents had occurred. We could not be assured events would be accurately reported to health professionals to help them make decisions.

The management team were not aware of their responsibility to notify CQC of certain events that happen within the service. We had not received notifications about potential safeguarding concerns as required.

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. Staff referred people to healthcare professionals when their needs changed. However, staff did not always share accurate information or work with relatives to ensure people received the most appropriate support.

Some people have been supported to spend time into the community. The service welcomed local churches and local history groups.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. The quality of the service had deteriorated significantly since our last inspection. There was not a culture of learning, systems in place did not identify and support learning opportunities.