St James's 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 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 and registered manager were in breach of the legal regulations relating to consent, dignity and respect and governance.

This service scored 43 (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, inclusion and engagement.

Most staff told us there was not a shared culture between staff and management. Comments included “I believe the dynamic between staff and management to be somewhat hostile,” and “A leader’s approach to personal care, appears to lack empathy and sensitivity”.

Due to the lack of mental capacity assessments in line with Mental Capacity Act 2005, the service could not be assured that people’s human rights were being upheld.

The registered manager had failed to identify undignified practices taking place.

This contributed to the breach in regulation in relation to dignity and respect.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

While we received some positive feedback from relatives about the management, this assessment identified issues that led to breaches of the legal regulations, which had not been identified by the provider and registered manager.

The registered manager told us they did not receive supervisions. The registered manager did not identify their own learning needs. This meant they were not aware of relevant guidance to support safe care and treatment. For example, they were unfamiliar with NICE (National Institute for Health and Care Excellence) guidance around the administration and recording of controlled medication and were not adhering to the provider’s policy.

This contributed to the breach of regulation in relation to safe care and treatment and governance.

Staff did not always feel they could speak up and their voice would be heard.

We received mixed feedback from staff about the management team being approachable. Comments included, “I think at the start I was a bit nervous of them but once you get to know them they become more approachable,” and “I raise the same things and nothing ever happens”.

We saw records of some senior staff meetings, however these records showed not all staff had attended a meeting.

People told us they felt they could raise concerns. One person told us, “I’ve never had to raise a complaint, I can’t imagine that I will need to. But I feel confident that (registered manager’s name) would take things seriously”.

The provider valued diversity in their workforce. However, staff did not always feel empowered and were not confident that their concerns and ideas result in positive change.

The registered manager told us they were able to make reasonable adjustments to support staff with specific personal needs, for example mental health conditions.

The provider had an Equality, Diversity and Human rights policy.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

Systems and processes were not robust enough to identify all the shortfalls found during this assessment.

The registered manager systems and processes had not identified institutional practices or ensured people were always treated with dignity and respect.

The providers systems and processes had not identified the fire risk assessment needed to be reviewed.

The providers systems and processes had not been effective in identifying the monitoring and servicing of equipment was out of date. For example, the suction machine.

Risks to people’s health and safety were not always assessed and monitored, and the Mental Capacity Act 2005 was not being adhered to. Staff were not always given clear guidance, putting people at risk of avoidable harm. The registered manager was not auditing care plans to ensure reviews were effective, sufficient information was included within peoples care records and current legislation was being followed.

This contributed to the breach in relation to governance.

The service did not consistently engage with external partners.

One professional told us, “The registered manager does not engage and there isn’t open communication.”

We observed the service working with occupational therapists while we were onsite.

The registered manager told us about the challenges they faced when collaborating with professionals for new people moving into the service.

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 quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had not acted on feedback received from people to improve their quality of life and experience of living at the service.

A risk assessment in relation to fire had been completed in 2022, this identified the shortfalls in relation to fire drills, however action had not been taken to address this concern.

Incidents and accidents were not analysed for themes and trends to identify any lessons learnt and continually embed good practice.

This contributed to the breach of regulation in relation to governance.