Carmel Lodge Care Home

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 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 inspection it has remained requires improvement. This meant the management and leadership was inconsistent and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider remained in breach of legal regulation regarding good governance.

This service scored 54 (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. We observe in several parts of the service some staff were focused on the tasks such as tidying whilst missing the opportunity to interact with people. We noted some people cared for in bed did not have drinks especially due to the weather being warm. The registered manager told us they were aware of the requirement to improve the service due to its previous rating of requires improvement. They were working hard to implement a structure and build a strong team and were working collaboratively with the staff and senior management to achieve this. The provider worked with quality assurance teams from the local authority, to review the quality of care and to implement improvements.

Leaders demonstrated an understanding of the context in which care, treatment, and support were delivered.

We received mixed feedback from relatives and staff about the management of the service, in particular, that managers had not always taken timely action to address issues, such as staffing shortages when concerns were raised. One relative told us, “Communication could be better here. You say something and you come back, and it is as if you’ve not mentioned it at all. They [management] don’t pass on information to staff.”

Staff feedback about management was mixed. Some staff described the registered manager as kind and approachable, while others raised concerns that management could be unapproachable or dismissive when support was needed.

The provider had not fostered a culture where people could speak up and their voice would be heard. However, people, and their relatives told us they were confident to raise concerns with the management team but sometimes felt these were not acted upon. We received mixed feedback from staff, some said they did not always feel they could speak up and would be listened to. Feedback from staff included, “I feel I can speak up. The office is always open to us, and they [management] are quite easy to talk to.” Information on how staff could raise concerns such as the whistle blowing policy was available.

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 told us they were treated fairly, and everyone worked well together as a team. Staff completed training in equality and diversity.

The provider had clear responsibilities, roles, and systems of accountability in place. However, their governance systems had not been wholly effective at identifying and rectifying the shortfalls found at this inspection. Audits and systems for checks were not being used effectively to identify areas or shortfall such as those we found in relation to care plans, risk assessments, medicines and safeguarding. Improvements were needed to the processes of oversight to drive improvement and ensure good quality records were maintained. Systems for oversight and quality monitoring were not fully established, which limited the provider’s ability to effectively identify, analyse, and address shortfalls. For example, there was a significant incident that required notifying to the local authority and CQC as a safeguarding, this had not been completed. We raised these concerns with the provider, who informed us that a new system was due to be implemented to improve management oversight of incidents.

During our last inspection, the provider was found to be in breach of Regulation 17: good governance. While some improvements had been implemented, they were not sufficient or embedded effectively within the service to result in a sustained and meaningful improvement. As a result, the provider remains in breach of this regulation.

An action plan has been requested to address the concerns identified.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, we found one incident which required notify to relevant bodies had not been completed. However, the provider shared most information and learning with partners and collaborated for improvement. For example, referrals were made to external professionals where this was required for people. We received feedback from the local authority, who said the provider was working towards achieving identified improvements.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. There was a lack of effective oversight and governance to enable learning and improvements to be made, Audits in place did not allow for clear oversight of the accidents and incident. We raised this with the provider, and we were informed a new system was due to be implemented which would allow management to have clear oversight of themes and trends of any incidents. Additionally, we found the registered manager was not always open and receptive to all of our findings. While they aimed to explain how systems operated, this was a missed opportunity to demonstrate a clear commitment to learning and improvement.