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 Requires Improvement. At this assessment the rating has changed to Inadequate.

This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

There was not always a clear or shared direction for the service. Limited provider level involvement had impacted the development of a positive culture, and there was no clear leadership through the registered manager to promote a positive culture throughout the service.

Staff morale was low and staff said there was a very difficult working relationship with the registered manager. The provider was aware of mixed staff morale and the concerns we highlighted during the assessment and had plans to address matters.

People and their relatives were clear about who the service management was, however, some comments indicated people living at the service had identified a disconnect with the service management and staff team. One person said, “I do wonder if there is some conflict between staff and the manager.” A relative said, “Nothing much has changed here except for the number of staff changes. Many just leave and go to another care home.”

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

While the registered manager was visible in the service, their current shift pattern did not evidence staff were supported at peak times of the day such as the mornings. This was when the service can be at is busiest with people requiring personal care when getting up. There was also limited oversight from the provider. The provider had not identified or addressed concerns from previous assessment findings, or the leadership concerns identified by staff in staff surveys or exit interviews.

The compliance manager had identified some of the concerns we found at this assessment. However, further concerns found at this assessment had not been identified or effectively managed.

Improvements were not always implemented in a timely way. For example,the concerns identified at the last assessment that resulted in enforcement action had not been fully addressed to ensure the regulations had been met. An action plan had been developed by the compliance manager, however more significant input from the provider was needed, including oversight and performance management of service management, to drive improvement quicker.

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

Staff raised multiple concerns with the assessment team about the registered manager and some team leaders not being approachable. Examples were given by existing staff where newer staff had left due to the way they had been spoken to. There was an evident relationship breakdown between a significant number of staff and the registered manager. This had resulted in a high staff turnover, low employment satisfaction and a demotivated workforce.

Staff comments included, “Staff are not encouraged to have an opinion, [registered manager] always manages to make you feel like you’re not very good at your job.” Another staff member commented, “We are told if we have any concerns regarding staff to try and sort it ourselves and then if that doesn’t work to go to [registered manager], but that doesn’t always help the situation.”

Staff were encouraged to speak up in exit interviews and surveys; however, this information had not been used by the provider to drive change or improvement.

No concerns were raised by people, relatives and external professionals about being able to raise anything with the management team.

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.

Whilst we identified there was a high level of dissatisfaction and low morale at the service, there was no indication of inequality towards any staff members. The provider was dedicated to supporting all members of their team and had commenced processes to address staff concerns and grievances. Staff did not indicate they did not receive the same opportunities to train and develop themselves.

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.

Systems operated by the provider were not robust to assess, monitor and improve the quality and safety of the service to ensure regulations were met. There was a lack of formal provider oversight which had resulted in the failure to identify concerns around the registered manager which has resulted in a continued breach of regulations. Although regular provider visits took place, these were not formally recorded, and there were no clear action plans produced by the provider to monitor progress or drive improvement. This meant while some actions were being discussed and taken, there was limited evidence to demonstrate how improvements were planned, tracked and sustained.

The compliance manager had completed audits and identified shortfalls and concerns in relation to care records and practice. This had resulted in an action plan being created. However, the absence of formal provider level oversight had not identified assigned actions to make improvements had not been completed by the nominated staff member as part of the role and responsibilities. The absence of a fully effective governance system placed people at risk of unsafe or poor care.

This contributed to a continued breach of regulation in relation to good governance.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The service worked with local GP surgeries and other healthcare services where required. However, the registered manager had failed to escalate a significant event relating to a controlled drug error to external agencies such as the local authority safeguarding team.

Healthcare professionals we spoke with did not raise any concerns about the working relationship they had with the service or the outcomes for the people receiving care. One professional said, “Our advice is passed on and no concerns, and communication is good.”

The registered manager told us links with the local community were limited but said a variety of local entertainers were used and cream teas and pasty days were held. They told us there were currently no links in place with any local schools, but this may be explored in the future.

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

Systems were in place to identify learning from incidents and accidents. However, there was limited provider level oversight to ensure wider learning was identified, embedded and sustained. Systems had failed to identify the management of learning, improvement, and risk was ineffective. For example, deterioration in people’s physical wellbeing was not identified or escalated effectively. This meant people would not always receive care, support and treatment in a timely way.

Meetings were held with people, their relatives or staff. Feedback was also sought via surveys and questionnaires. However, there were currently no effective systems in place to learn from the feedback supplied through these meetings and surveys. For example, significant concerns had been highlighted about the service management and staff morale through exit interviews and staff surveys, however this had not resulted in any action being taken to drive improvement or stabilise staff retention.