Dunraven House and 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 changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The service was previously in breach of legal regulations in relation to governance. At this assessment we found the service was no longer in breach of this regulation.

This service scored 64 (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 always understand the challenges and needs of the people and their communities. Although there was a clearly defined vision and strategy, further work was needed for this to be fully embedded.

For example, a manager had spoken to us about how they were developing the service and working to change the culture to improve people’s choice and independence and to develop facilities provided, such as the new kitchenette. However, further time was needed for people and staff to fully embed and embrace these changes.

Although the recent closure of the day service was seen as a positive by people, some staff viewed this as a negative. Comments included “I’m not sure it’s a good thing that they closed it”. This meant staff did not recognise the positive impact this had for people, for example people’s access to the community and their experiences had increased, this also meant staff did not fully understand the principles of a positive culture.

The provider had developed drink stations for people to help themselves to a drink. However, we saw several people asking for permission to make a drink. We found the drink stations were not placed in areas visible for people to see easily and some people told us they were unsure whether they were allowed to use them without staff approval. A member of staff asked someone who was drinking a glass of water if they wanted a drink. The person replied: “No, thanks” but the staff member went and got a glass of squash for them. We discussed this with managers in the service, who told us they were focused on supporting independence but recognised this would take time to change the culture.

This meant people’s independence was not consistently promoted, and staff actions sometimes undermined opportunities for people to make their own choices about everyday tasks.

Team meeting notes included the provider discussing future plans for service improvement with staff. However, these future plans were not included in discussion with resident meetings.

This meant people were not always involved and informed about decisions that would shape their daily lives and were not always offered the opportunity to understand, question or influence changes that directly impacted them or their home. This also meant, people’s voices were not embedded in the provider’s improvement plans, limiting transparency and reducing opportunities for people to be active in their own support. We discussed this with the provider who told us they had only recently implemented these resident meetings

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Feedback we received from most staff and all relatives showed that leaders were compassionate, inclusive and trustworthy. Staff were happy and confident in how to perform their duties. Comments included, “[Managers] are client focussed,” and “[Staff] are caring and interactive. [My relative] has a good staff team, with one person going above and beyond their remit”. People confirmed this with comments including, “I feel [manager] gets me, they don’t judge” and “To be honest, I put a lot on [manager,] sometimes at silly times and they are always wise”.

However, three staff told us that some of the managers “Could be dismissive at times”. We spoke to the provider about this who had a vision for developing the service management structure. This had already begun, with one manager registering with the CQC for registered manager status, and another newly employed manager who had been in post for one week at the time of our assessment.

Some leaders spoke confidently about the right support, right care, right culture model, having recently been on a course. Managers had also either achieved their leadership qualification or were in the process of studying it.

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

The provider had a whistleblowing policy which had been reviewed, and staff knew how to raise concerns. Staff told us: “I would absolutely speak up – and I have done in the past,” and “I have felt supported when I needed to speak up”. Managers confirmed this by ensuring accessible information on how to escalate concerns was available to staff.

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.

For example, during our assessment, we saw female staff in uniforms but male staff were in casual dress. This was not in line with the provider’s policy. Some staff had told us they had asked for spares, we saw this as a point for discussion in team meeting notes. Managers confirmed uniforms were only provided for female staff and not for male staff, meaning male staff were not given the same level of practical support or professional workwear as their female colleagues. This demonstrated an inequitable approach and did not promote an inclusive working environment. Managers told us they were aware of this issue and the provider was reviewing this.

This meant the provider did not always ensure equitable or fair treatment across the workforce. Staff did not consistently receive the same practical support or structured opportunities to share their views. As a result, the provider could not be assured that all staff felt valued, represented or included, and important workforce issues may not be identified or addressed.

However, the provider did ensure that pregnant staff had a risk assessment, although this was generic and was not personalised to the individual.

The provider also ensured team meetings contained opportunities for staff to share updates, raise concerns and discuss any changes they felt would affect the delivery of care.

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.

During our previous assessment we found shortfalls in relation to good governance. During this assessment, we found the provider was no longer in breach but had not addressed all of the shortfalls.

At the previous assessment, the service was not meeting all the statutory requirements of right support, right care, right culture guidance. During this assessment, the provider had not made sufficient progress to improve person centred care and meet right support right care right culture. While we saw some improvements and managers described where action had been taken or was being planned, we continued to see areas that needed embedding or further work. For example, people asking staff for permission to make drinks, staff‑led routines shaping people’s daily lives, and communal spaces arranged in ways that did not support independence or choice. This meant the governance processes in place had not fully addressed all shortfalls and people did not always experience autonomy, personalised decision‑making or full control over their day‑to‑day lives.

Although medicines were managed safely, people that could be assessed and supported to self-administer medicines had not the opportunity to do so. For example, this had been highlighted in the previous assessment, and during this assessment, the provider had not made enough improvements to enable people with capacity to manage their medicines independently. Audits had not highlighted opportunities for people to self-medicate. This meant the provider had not driven improvements in areas that would impact positively on people’s lives.

We spoke to the provider about this who told us they had ordered a lockable cabinet for someone, and they were in the process of supporting them to self-medicate. After the assessment, a manager informed us two people now had their medication stored in their room.

Although the provider had made improvements against the shortfalls found during the previous assessment and had identified to us areas they planned to make improvements in, they did not have systems and processes to ensure action was taken in a timely way and responsibilities clearly identified. This meant the provider could not ensure shortfalls were being actioned in line with their vision.

Furthermore, although the provider undertook IPC audits, these had not recognised shortfalls in some areas. For example, the provider used the ‘Safer Food Better Business’ model to record findings within the kitchen, but these had not identified the food storage shortfalls we found.

General home and staff related risk assessments did not always contain comprehensive information to mitigate risks. For example, governance systems had not identified lacking information within the service fire risk assessment. The registered manager told us they were in the process of transferring risk assessments to a new format.

It had not been identified through governance audits that people’s personal information regarding their health had been fixed to the wall in a communal area. This meant people’s privacy and dignity was not always upheld.

Furthermore, processes for capturing and acting on learning were inconsistent. For example, audits such as safer food better business records had not identified the condition of one kitchen area. This meant the provider could not be assured that improvements were consistently sustained and embedded or that similar issues would be prevented in the future.

One manager had actively sought further learning to support and drive improvements in governance. This meant the service at times benefited from leadership that was committed to developing the skills and knowledge needed to strengthen oversight, support staff, and improve the quality and safety of the service

The manager recognised further service improvements were required to embed the changes that had been made in order to improve people’s experiences. For example, the registered manager and another manager told us about the plans they had to establish a more homely environment and showed us the newly created living and communal spaces which included a kitchen and lounge. This meant people would have a homelier environment to spend time in.

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.

This included a situation where a person’s needs had recently changed. In order for the person to receive the right support, the provider ensured they had open communication channels with the speech and language team and GP service.

The provider told us they worked with a range of other professionals to help make sure people received continuity in their care. This included handover and transition periods for people having short treatment stays in hospital. People told us that the provider would visit them in hospital during these periods.

The provider understood the importance of accessing the community and supported people to find events and gatherings that were of interest to them. For example, attending support groups for a person who was at risk of addiction, seeking work opportunities for people and trips to see friends in neighbouring counties. This meant people maintained a social life and the risk of social isolation was reduced.

The provider did not always demonstrate commitment to learning and improvement and systems were not always effective in embedding lessons across the service.

Although leaders demonstrated examples of learning from the previous assessment, such as promoting people’s access to the community, managing people’s risks to their health and person-centred principles for care planning, other areas such as promoting people’s independence and choice still needed further improvement and embedding.

Despite this, staff told us they felt encouraged to share ideas, and leaders had begun implementing measures to strengthen oversight and drive continuous improvement.