Compassionate 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.

This is the first assessment for this service. This key question has been rated 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 legal regulation in relation to the overall governance at the service.

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.

The provider promoted a culture that recognised and respected people’s individuality, ensuring care was inclusive of people’s diverse backgrounds, cultures, beliefs and preferences. They fostered a positive and supportive environment where people were treated with dignity and respect, and care was delivered in a person-centred way. Staff spoke positively about the management team and described feeling valued and supported in their roles. This positive culture was reflected in the way staff interacted with people, promoting their rights, choices and independence.

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.

The registered managers demonstrated a commitment to improving outcomes for people and promoting a positive culture within the service. They responded promptly to concerns identified during this inspection and took action to address environmental issues raised during our visits.

People and staff were encouraged to contribute to the development of the service and share their views. Meeting records and feedback received during the assessment showed people and staff had opportunities to participate in discussions about the running of the service and suggest ideas for improvement.

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

People and relatives were encouraged to raise concerns, and systems were in place to support this. We saw a person living in the service had raised a complaint, which was investigated appropriately by the registered manager and shared with relevant professionals for their input.

Staff told us they felt able to speak up and raise any concerns. A staff member told us, “It means staff can raise concerns about safety, care, or the workplace without fearing unfair treatment. Managers encourage us to speak openly.”

The registered manager had made sure staff knew how to access the service's policies and procedures. This included their whistleblowing policy.

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.

Systems were in place to support equality and ensure employees received appropriate support to carry out their roles.

As part of the recruitment process, prospective employees completed a health questionnaire. This helped the provider identify any health needs and consider reasonable adjustments or additional support where required.

The provider had clear responsibilities, roles, systems of accountability and governance in place. However, these were not always used effectively to identify and act on information relating to risks, performance and outcomes, or to ensure relevant information was shared appropriately with others when required.

The provider had systems and processes in place to monitor the quality and safety of the service. However, these had not always been effective in identifying and mitigating environmental risks. During our inspection, we identified several environmental concerns which had either not been detected by the provider's monitoring systems or had not been addressed appropriately, placing people at risk of harm.

Staff knew people well and consistently supported them in line with their individual needs and risk assessments, which contributed to people's safety and wellbeing.

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.

People received appropriate support from other agencies and professionals in a timely way through the support of staff.

A visiting professional commented, “This is an excellent and reliable/ committed care provider that has worked really well with a number of my complex people who have a diagnosis of severe and enduring mental illnesses.”

The provider did not consistently promote a culture of continuous learning, innovation and improvement across the service. Opportunities to develop creative approaches to improving people's experiences, outcomes and quality of life were not always identified or acted upon. In addition, the provider's contribution to improving safe and effective practice was limited, which meant people did not always benefit from service improvements.

The provider had notified CQC about an incident where a person, who was living in the home, left the home through a ground floor window because appropriate window restrictors were not in place. Following this, the provider installed additional window restrictors on some windows in the home. However, when visiting we identified a lack of compliant window restrictors throughout the home, including on first floor windows. Therefore, the provider had not followed relevant Health and Safety Executive guidance and lessons had not been learned following a previous incident. This meant people were at risk of falling from or through windows, which could result in serious injury or death. The provider was receptive to our feedback and responsive by arranging to instal compliant restrictors.

Although the provider had systems in place to analyse and learning from incidents, this was not always effective in practice.