Sands 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 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 good governance and fit and proper persons employed; this was because of failing to identify and address failings identified in this report as well as gaps in employment checks.

This service scored 62 (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.

The provider had stated values and commitments relating to person-centred care, choice and responding to people’s individual needs. However, these were not consistently understood, embedded or reflected in practice across the service. This meant there was not a clear shared vision or culture that consistently promoted transparency, equity, inclusion and respect for people's rights.

As outlined elsewhere in this report, people's wishes, preferences and views were not always actively sought, considered or reflected in decisions about their care and support. We also found that people did not always experience the same level of choice, control or involvement in decisions affecting their daily lives. As a result, the provider did not always demonstrate an understanding of the challenges, needs and experiences of all people using the service, and people's outcomes were not always equitable.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support.

We found that the registered manager of the service was responsive to our feedback and findings. They worked closely with our inspection team with integrity, openness and honesty. They led their team with compassion, empathy and kindness. For example, when they received a bonus from the provider, the registered manager shared this with the team as a gesture of gratitude.

Staff, people and relatives shared overwhelmingly positive feedback on the registered manager. One person told us, “[Registered manager] is lovely, I can talk to [them] if I need to. Staff told us, “[Registered manager] is very approachable and supportive. [They] listen to any concerns we may have and take appropriate action when needed. [They] are available to support us whether we are working during the day or at night. I feel that [they] always go the extra mile to support both the residents and staff.” Another staff member told us, “Yes, our manager is very helpful to the staff and [they] are avery good leader. [They] are always helping us to learn a lot and providingthe staff with training and workshops. I am so proud as one of the staff at Sands to have a manager like [Registered manager].

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

People and staff at the service felt confident of being able to speak up. They knew the procedures and who they could approach, leaders were also visible and accessible to facilitate this. The registered manager operated an open-door policy for all at the service and contact details were available for senior leaders in the organisation. People said they could speak up should they need to. A person said, “Yes I could, they would do something!” Another person told us, “Yes, I could, I’d just tell the staff. Yes, I think they would act.”

The service also had options to confidentially raise concerns through a portal that were accessible via QR (Quick Response) codes that were available throughout the service including in bathrooms.

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 provider had relevant policies in place and followed these when supporting their workforce. Equal opportunities were considered for each staff member, and these were recorded in their staff files.

Staff were treated fairly, with leaders taking a flexible and supportive approach that recognised individual needs and circumstances.

We noted during our inspection a diverse workforce who supported individuals well. A staff member said, “l just wants to add a little bit more about my manager. [They] are a good manager, [they] are very nice, caring and a hard-working manager. There have been so many good changes within the service ever since [they] joined Sands Lodge. [They] have taught us new things that we love, [they] also introduced different activities and ideas that make the work more interesting. We also have theme days in the kitchen and [people] get involved with preparing different food for cooking. [Registered manager] clearly loves what they do and [they] put their heart and soul into Sands Lodge.”

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.

We found that some audits in the service were not effective at leading to change, a quality assurance audit failed to identify that there were gaps in employment records. When they did highlight concerns for example regarding COSHH these were not followed up on or actioned.

We were not assured that the provider followed their own policies and found an instance where what was stated in the policy was not actioned.

As highlighted in other areas of the report, risks were not always identified or mitigated in order to keep people safe from avoidable harm.

We found that documents were not always completed for example those relating to staff development were not signed by the named parties resulting in lack of accurate records that these had been carried out effectively.

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.

The provider had many examples of good partnership working, for example the service had a period of medicines errors from a local pharmacy. The service identified these, raised them with the pharmacy and then gave constructive feedback as well as meeting with the leaders of the business. This led to positive changes and ultimately led to improved medicines oversight at all levels.

The provider regularly engaged with professionals and arranged guest speakers for people and staff at the service. There was positive working relationships with emergency services when the need arose as well as the local authority social services team.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The provider ensured that staff were well equipped and supported to care for the people at the service. For example, the service had a ‘Know your residents, diagnosis information’ folder. This highlighted 30 different conditions that people at the service may be diagnosed with. It gave overviews of conditions, signs and symptoms and advice on how to support along with other resources. The registered manager told us that this resource has led to increased knowledge and better support for those who live at Sands Lodge.

The provider had developed an ‘on call’ folder to guide and support staff in the event of incidents or events that require management support. This included contact details, local authority safeguarding guidelines and a robust policy. Also included was a log of all on call support used, this was analysed for trends so that refinements could be made and lessons learnt.

The above along with bespoke training and development delivered by the registered manager supported staff in their roles.