The Lodge - Dementia Care with Nursing

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 remained 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 the legal regulation in relation to good governance.

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.

Leaders at The Lodge told us they aimed to deliver a high-quality service for people with dementia and their families, encouraging people to be independent where possible. This was shared and discussed with staff throughout their recruitment journey, during induction and staff meetings.

There were appropriate policies and training regarding equality, diversity and inclusion.

Leaders did not always lead effectively. Although there was a stable management team, there was not enough improvement following the previous assessment, and we identified repeated breaches of the legal regulation regarding aspects of governance at this assessment. Other professionals shared the same concerns. However, staff told us managers were approachable and supportive. There was a thorough induction and training programme which staff spoke complimentary about.

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

There were appropriate whistleblowing policies. Staff said they felt able to speak up about any concerns they had and were confident they would be listened and responded to.

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.

There were appropriate policies and procedures to support and value equality, diversity and inclusion. Staff did not note any concerns in this area.

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.

Although there were performance monitoring and audit schedules in place, the audits had not identified some issues found during the assessment, such as limited guidance, and discrepancies in care plans. We found there was a delay in managers being aware of some incidents, meaning lessons could not be learned in a timely way. We did not find any evidence of harm, and when we fed this back the management team put in measures immediately to ensure they had adequate oversight of incidents.

There was a registered manager who had been in place for more than 2 years. The registered manager made statutory notifications to relevant bodies which is their legal duty to do so.

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 established links with external agencies and developed and maintained productive working relationships with the local GP practice and health board. Links were made with the local community such as schools, military veterans, and scout and guides groups. Faith leaders held church services at the home and staff supported connections with the local Imam.

The provider organised fundraising days to support local charities.

The provider did not always focus on continuous learning and improvement across the organisation and local system.

Improvements needed to be made to make sure that all incidents including low level, were properly documented and reviewed in a timely way, and to make sure any lessons were learned to improve practice. The provider made changes following our feedback, including recruitment of staff to oversee governance processes.

Leaders of the service participated in local conferences and forums to complement their skills, knowledge and experience.