Priory 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 inadequate. 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 provider was in breach of legal regulation in relation to good governance.

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 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.

There was a consistent management and staff team at Priory Lodge and staff told us they felt supported to raise any concerns to management. Staff were passionate about the people they cared for and spoke positively about working at Priory Lodge. Comments included, “Management are approachable and supportive” and “Management operates total transparency and is constantly approachable, this creates a culture of trust where I feel safe to voice ideas or concerns.”

Feedback from staff around supervisions, the induction process and training was positive. Staff told us they felt able to ask for any additional training or support if required.

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.

People, their relatives and staff we spoke with were positive about the management at Priory Lodge. Comments included, “I agree 100% that our management is available for staff and residents. I know I can come anytime and ask for advice and also have their support” and “Priory Lodge provides a supportive, welcoming environment with devoted staff and leaders.”

The registered manager explained how they had supported staff to enrol onto relevant health and social care qualifications to support their career development since our last assessment and increased the number of supervisions to help support staff within their roles.

The management team were responsive, open and honest throughout the assessment and responded positively to feedback given.

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

At our last assessment we found that staff were not receiving regular supervisions. However, at this assessment we found that there had been an increase in the number of supervisions that staff were receiving, and staff feedback confirmed this was having a positive impact on staff wellbeing. Comments included, “Management consistently encourage me to improve and believe that every member of staff can achieve their goals.”

The registered manager told us that since the last inspection, they had implemented that staff completed health and social care qualifications from level 2 up to level 5 depending on their role and we saw evidence that staff were enrolled or had completed these qualifications.

Staff told us they felt comfortable raising concerns with the registered manager and supported to do this. One staff member told us, “Management are very visible and easy to talk to. They always make time for a quick chat.”

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 a policy in place for equality, diversity and inclusion. Staff had completed training in equality and diversity.

Feedback from staff was positive about being treated fairly at work and staff told us they felt that any concerns they raised would be acted on. We observed a positive culture during our onsite inspection.

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.

The provider had processes in place to monitor the quality of the service; however, these were not always effective. We identified a number of gaps in peoples care plans and risk assessments and processes had not picked up that one person’s care plan had no risk assessments in place and no PEEP in place.

We found concerns around IPC and despite audits being carried out, these had not identified areas of concern around cleanliness and food storage.

Governance systems were not effective in ensuring medicines were administered safely. Audits had not been effective in identifying areas for improvement, such as medication stock, PRN protocols and administration practices.

The provider acted quickly on areas of concern and feedback we provided; however, these had only been completed after issues were raised during the assessment. For example, ensuring people had the appropriate information contained within their PEEPs and risk assessments.

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.

Staff recognised the importance of maintaining close connections with external healthcare professionals and for people to maintain access to the local community. Comments from staff included, “Staff help to provide support with activities, appointments, and community involvement, and actively encourage choice and independence” and “People seem happy and empowered to live as independentlyas possible.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had failed to ensure the necessary improvements despite their previous CQC ratings. Audits, though being completed, had not always identified the issues we found. This meant it was not always clear how the provider consistently drove improvement, identified concerns and how they learned from these. We found no evidence people had been harmed. The provider acknowledged that improvements were needed to make sure people always received high quality care and support.