Grove 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 remained 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 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.

Management told us the ethos of the home was for person centred care, a home from home and they prided themselves on home cooked food. One relative told us “my relative enjoys the food, the chef is good, it’s proper food, meat and two veg and proper fry ups. They know what my relative likes, their favourite foods. They accommodate their food choices, –my relative loves scrambled egg and ice cream. They have put on weight since being here which they needed to”. A staff member told us, "I Love my job. We are a really good team who work well together and help each other out.”
 

Leaders were visible within the service and lead by example to their staff team, demonstrating inclusive behaviours.
We received positive feedback from staff about the management team at Grove Lodge. One staff member told us the registered manager, “Is the best manager I have had. They lead by example and are always there if I have any concerns. They are very empathic too and care about us staff.”
 

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

Grove Lodge had policies and procedures to support staff in speaking up and raising concerns. Staff told us they felt able to raise anything they felt was important, and they were confident that management would take their concerns seriously and address them.
 

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.

Not all staff had completed equality, diversity and inclusion training. However, we received positive feedback from staff about working at Grove Lodge. Staff told us that they felt valued and supported. Staff did not express any concerns about their own treatment or that of other staff.
 

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, or share this securely with others when appropriate.
Governance was not always reliable and effective. The provider completed multiple audits, however, systems and processes in place did not identify concerns we found during the inspection. For example, systems and processes for auditing medicines did not identify or address concerns with medicines records found during our assessment. This placed people at risk of not receiving their medicines as prescribed.

The fire risk assessment had not been reviewed recently and mitigating factors for not carrying out fire drills were not robust. There was no water hygiene risk assessment in place. This placed people at risk of harm from hazards in their environment. Following our feedback, the management team took immediate action in these areas. However, we have not been able to assess the effectiveness and sustainability of this process.

The training matrix demonstrated staff had not completed some of the required training for their role for example, diabetes, mental capacity act, dignity in care and falls. Staff were not receiving effective supervision sessions. Supervision sessions were not an engaging and participant focused experience. This meant people were at risk of not being supported in accordance with their needs.

Policies did not always provide up to date guidance for staff, had not always been fully completed to reflect the services requirements nor were they always followed. For example, we found no evidence that controlled drugs medicines stock was regularly checked, and the medicines policy did not provide guidance around this in line with best practice. This meant people were at risk of harm of medicines errors occurring and remaining undetected
The recruitment policy was not always followed as 2 staff members did not have references in place. This meant that staff were not always recruited safely.
Policies were due to be reviewed during our assessment. Policies had not always been reviewed when required, as determined by the provider or when changes occurred. For example, when the named safeguarding lead left, the policy was not updated to reflect this. Following our feedback, the safeguarding lead was updated in the policy, during our inspection.
 

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.

We received positive feedback from professionals about how Grove Lodge worked in partnership with them. A professional told us, “The manager’s actions reflect a strong commitment to the health, safety, and wellbeing of residents.”
 

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.

There was no action plan in place to drive improvements and learning within the service. Not enough improvements had been made since our previous inspection. However, whilst we did identify shortfalls during this assessment, the provider was responsive to our findings and acted immediately on areas of improvement.