Walton 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.

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

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.

The management team accepted the findings from the assessment and worked proactively to implement timely improvements. They were keen to improve the service for the benefit of people and were open and honest through the assessment. The registered manager understood the duty of candour and the importance of acknowledging mistakes made.

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. We could not be assured leadership at the service was effective in monitoring the safety and quality of the care people received. For example, there were gaps in the leaderships team’s knowledge around the management of risk and processes to manage accidents and incidents. The provider had begun to make changes prior to and during our assessment including a number of recommendations about reviewing systems and processes and further training for staff.

People did not always feel they could speak up and that their voice would be heard. The processes in place to support staff to raise concerns had not ensured that staff felt listened to or that concerns or suggestions raised had been considered and acted upon. One staff member said, “The staff don’t feel comfortable to raise and concerns they have with anyone above the position they work in. Support staff don’t have a voice!” Another staff member said, “We had team meetings [not once a month like we were supposed to] many concerns were voiced by staff and very little action were taken to resolve these concerns.”

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. Policies and procedures were in place to support the workforce. Staff had access to support through both formal and informal supervisions.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

The provider’s quality assurance systems did not identify the concerns we identified at this assessment and were not used to drive improvement. People were not always involved in making decisions about their care. The provider had failed to act on a known risk. Lessons learned were not always identified through accident and incident monitoring, meaning lessons learned were not always shared with staff.

Systems to assess, monitor and reduce risks to people’s health care and safety were not robust. People’s care plans were not always detailed and accurate. Risks or hazards were not always identified and/or assessed. Where risks had been identified, risk assessments did not always contain clear guidance to ensure staff, including newly recruited and temporary staff, remained well-informed on the safest ways to support people.

The provider had begun to make changes during our assessment including seeking professional guidance, further training for staff and reviewing systems and processes.

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. Information was provided about significant events for people. The registered manager attended meetings to share information and gain support.

The management team acknowledged the shortfalls identified during the inspection and took immediate action to address the concerns. The registered manager confirmed that Walton Lodge had a service improvement plan in place, which was a live document. Actions were added to the service improvement plan from all internal and external audits, as well as anything identified by the manager, the regional operations manager, and other support services. Following recent whistleblowing concerns, the team had taken immediate actions in a variety of areas, and work remained ongoing. The provider was open and transparent throughout the assessment process and demonstrated a willingness to make changes to improve the quality of care for people.