South Haven Lodge Care Home

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 Inadequate and found 1 breach of the legal regulation in relation to good governance. At this assessment we found improvements had been made and the service was no longer in breach of the legal regulation in relation to good governance.

The rating at this assessment has changed to Requires improvement this is because the improvements that have been made require time to be embedded into practice and sustained.

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.

At our last assessment we were not assured the provider had a shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. At this assessment we found improvements in this area.

Throughout our assessment visits we observed care being provided and people being supported in line with the providers values. We found people were supported to be part of their communities and the service promoted people making their own choices and having control of their lives. The staff and leaders, we spoke to cared about the people they supported, their relatives and each other as a staff team.

There was evidence of improved auditing processes and increased oversight of people’s care to ensure all people had the same opportunities and care records, observations and discussions with staff and people demonstrated people received person-centred care.

At this assessment changes had been made in relation to the manager of the home and the senior leadership team of the organisation. We found 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. These leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

A member of the senior leadership team told us, following the last assessment, “we have had a total restructure of staff at all levels. Previously there was no direction but a really feel things are improving and we have turned a corner. There is still work to be done and we know improvements will need to be embedded, but we are confident improvements will be continued and ongoing.”

Evidence showed senior leaders understand the context in which care needed to be delivered in a compassionate and inclusive way and from discussions with the manager and senior leaders and written evidence we were assured these leaders had the necessary skills and knowledge to ensure people were provided with continued effective and safe care to people.

At the time of the assessment visits people and relatives were generally positively about the management team and the overall running of the service. A person said, “I like it, I don’t have any concerns.”

Staff also talked about how the service has improved over the last few weeks and their increased confidence in the overall management. A staff member said, “The manager is really good, there have been so many improvements in the short space of time she had been here.” Another staff member told us, “You can really see things have got better, communication, activities, personal care, training and staffing have all improved and I feel much better supported and valued now.”

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

At this assessment we found improvements had been made to the overall governance of the service. The provider had developed clearer responsibilities, roles, systems of accountability and good governance. However, the changes made needed time to be sustained and embedded into practice.

From discussions with the management team, they demonstrated they had a clear understanding of their own, members of the senior leadership team and the clinical leads, roles, responsibilities and accountability.

Various systems and processes had been put in place to support both the management of the service and staff to help ensure safe, effective and person-centred care was provided at all times. These included the introduction of more robust and streamlined audits and processes being completed, including but not limited to, staffing levels, assessment processes, call bell response times, care plan and daily record audits and more extensive provider oversight.

Systems had also been implemented to ensure ongoing monitoring of staff practices to help ensure care was provided as required and in a safe and effective way to meet people’s needs.

Although improvement was noted some areas required further work to ensure continued improvement and safety will be maintained. For example, environmental processes failed to identify some of the issues we found and risks in relation to lack of access to fluids and call bells and to ensure care was provided as per peoples assessed needs had not been identified. These concerns were discussed with the management team and assurances were given that these issues were be addressed.

We will check for sustained improvement at our next assessment.

At this assessment we found some improvements in the provider and leadership teams understanding of their duty to collaborate and work in partnership, so services worked seamlessly for people. Evidence showed actions had been taken to improve the sharing of information and learning with partners. However, continued efforts were required to cement seamless and collaborative working relationships with partner agencies and professionals.

We continued to receive mixed feedback from health and social care professionals in relation to effective partnership working and learning and working in collaborative to drive improvement; with some professionals reporting a lack of responses from the service in relation to past safeguarding concerns and a history of failure to act in a timely way to past concerns. The leadership team were working to address these issues.

At this assessment we found the provider was acting to make effective improvements following CQC’s findings at previous inspections and assessments. Detailed action plans had been developed detailing concerns, and action they would take to implement improvements. This action plan and the completion of actions was an ongoing process.

Multi-disciplinary meeting continue to be completed weekly at the home which supported people to access health and social care support in a timely way. People’s care records demonstrated they had access to health checks such as dentist, opticians or chiropodist.

We received positive comments from relatives in relation to their involvement and inclusion in decisions about people’s care. A relative said, “There are regular assessments, and I am involved with those. The home phones regularly for updates on how I feel things are going and I feel they listen.” Another relative told us, “They [staff] phone me if there are any updates or issues. They have a resident of the week and phone me to go through the care plans. I do feel listened to.”

At this assessment we found improvements had been made to promote continuous learning, innovation and improvement across the organisation and local system. The provider and leadership team were actively working towards establishing creative ways of delivering equality of experience, outcome and quality of life for people.

At this assessment it was evident the concerns we found previously were taken seriously and were being addressed. Governance processes and audit systems had been and were being developed and put in place to help ensure the safe running of the service. These systems helped the provider and leadership team to identified issues and concerns in a timely way and act on these to drive ongoing improvement. Systems were in place to analyse incidents, monitor quality and inform learning and improvements.

The service had a service improvement plan and an action plan with systems and processes to address certain issues. However, these action plans did not always address the shortfalls we found at this assessment. The concerns we identified at this assessment were taken seriously and addressed by the leadership team.

Staff confirmed they now received clear and detailed guidance in relation to mitigating known risks to people. Staff demonstrated an understanding of people’s needs and how to support people safely considering their specific risks. Staff were able to demonstrate past incidents or near misses experienced by people were considered to mitigate and minimise future risk of harm.

People and relatives confirmed they were asked for feedback via feedback surveys and from face-to-face discussions with the management team and staff.

The changes made and being made in relation to leaning, improvement and innovation were very much in their infancy and would need to be sustained and embedded into practice. Therefore, we will check for sustained improvement at our next assessment.