Derwent 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. This meant that the governance processes did not always support the delivery of high-quality, person-centred care.

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

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders had set out expectations for staff behaviour and standards of care; however, these were not always consistently embedded in practice.

Leaders set a clear vision and positive culture. A vision, mission and values for staff were in place and clearly displayed.

Managers were clear about the standards they expected. Team meeting minutes showed they identified areas for improvement and outlined how they expected staff to act, including challenging poor practice. Staff we spoke with understood these expectations and told us they would raise concerns with management where needed. However, assessment findings demonstrated that standards of care, including infection control practices, were not always met in practice.Evidence was provided following the assessment visit demonstrating systems put in place to improve oversight of infection control practices. Team meeting minutes were also provided showing that managers had reinforced the standards of care they expected from staff following the assessment visit.

Leaders were compassionate and inclusive. Leaders monitored the service and took action to improve the service though they had not identified and addressed the issues we found during this assessment. Team meetings showed clear communication between management and staff.

People consistently praised the manager. A relative said, “‘[The registered manager] is approachable and supportive. [They] keep me informed and answer any questions I have.” Another relative said, “[The registered manager] is great. Seems to be really on the ball. A really nice disposition, very hands-on.”

Leadership was described as supportive and visible. A staff member said, “I love [the registered manager], [they] make me feel welcome.” Another staff member said, “[The registered manager] is helpful with any questions that I may have.”

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

People said they felt able to raise concerns. No people who used services or relatives reported feeling unable to speak up. Staff were confident raising issues with management and felt they would be acted upon. A whistleblowing policy was in place.

Team meeting notes showed evidence of staff being given the opportunity to speak up and drive improvement.

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 were in place to support workforce equality.

Staff raised no concerns in this area and told us they were treated fairly by management.

Governance and management systems were not fully effective.

Governance processes were in place and there was a range of checks to monitor the quality of care being provided. However, these processes had not identified and resolved the issues we found at this assessment. These included weaknesses in infection, prevention and control oversight and shortcomings in environmental safety and maintenance.Evidence was provided following the assessment visit demonstrating systems put in place to improve oversight of infection, prevention and control and environmental safety and maintenance.

The CQC rating was not clearly displayed on the Provider’s website.Evidence was provided following the assessment visit demonstrating that the CQC rating was clearly displayed within the home.

Not all actions identified by internal and external audits had been addressed promptly.Evidence was provided following the assessment visit demonstrating that actions identified by external audits had been addressed.

Notifications were made to the CQC as required. A registered manager was in place. A business continuity plan was in place.

A range of policies were in place regarding information governance and the use of information. The provider had achieved an ‘exceeded’ rating for the Data Security and Protection Toolkit standards.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

Staff worked effectively with external healthcare professionals and partner agencies to support people’s care and wellbeing. Information was shared appropriately to ensure continuity of care, including when people accessed other services.

The provider engaged with partners to share learning and improve outcomes, and professionals spoke positively about the service’s responsiveness and willingness to act on advice. Processes were in place to ensure suitable referrals to other community partners and agencies and had been appropriately followed by staff.

The service was committed to continuous learning and improvement. Staff completed a range of audits and areas for improvement were discussed at team meetings and through staff supervisions and appraisals. However, these processes had not identified and resolved the issues we found at this assessment.Evidence was provided following the assessment visit demonstrating additional systems put in place to improve management oversight and additional communication with staff reinforcing management expectations of the standard of care provided by staff.

A professional commented, ‘The nurse at Derwent Lodge is highly receptive to support and constructive feedback from the enhanced clinical practitioner and reacts positively with guidance. I believe this demonstrates a consistent willingness to reflect on their practice and implement improvements where needed.’