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 care; supported learning 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, while there was a positive culture; the governance, oversight and management of the service had been inconsistent and did not consistently support the delivery of high-quality, person-centred care.

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. Processes were in place to promote equality and diversity for the people the provider supported and the staff team. The registered manager told us, “We are involving staff about the reason why people are coming in and offering support. We are all working to move forward together as a team. With the senior leadership team on board, they have really been getting stuck in, we are demonstrating a whole team approach. We are demonstrating our values with commitment as a whole team.”

At this assessment further 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. However, they needed more time to continue to make positive improvements and embed those changes into practice.

A member of the senior leadership team told us things have been difficult, there had been a high turn over of managers and senior leaders, however, they were engaging with partners in care to make improvements. The leadership team and the manager demonstrated their understanding of the requirement to deliver care in a compassionate and inclusive way. Following discussions with the leadership team and the manager we were assured they had the necessary skills and knowledge to continue to improve the service and to provide safe and effective care to people. Time was needed to embed the improvements they were making into practice.

Relatives had confidence in the new manager and found her to be friendly and approachable and felt optimistic about the future. One relative told us, “She [manager] is improving the home.” All relatives felt they were listened to and that things were better recently.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff members told us the registered manager had an open-door policy and felt they would be listened to. Relatives told us their own, and people’s views were sought at meetings and when concerns were raised, they were sorted out. People and their relatives were involved in monthly reviews of their care. Updates on action plans were provided in the following meeting. This meant people’s views were listened to and drove improvement.

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. The manager told us, “We have space for staff who may need to pray, we support staff adjusting hours due to Ramadan. We adjust and are open to requests from staff. Some staff attend church on a Sunday, and we try and accommodate this where possible.” Staff felt supported to give feedback and were treated equally, free from bullying or harassment. They told us they had access to relevant policies.

At this inspection we found the provider had made improvements to the overall governance of the service. As at the last inspection, 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.

The management team and staff demonstrated they had a good understanding of their own, members of the senior leadership team and the clinical leads, roles, responsibilities and accountability.

Although improvement was noted there were some areas which required further work to ensure continued improvement and safety is maintained. Systems and processes failed to identify some of the risks and concerns we found in relation to medicines management, safety of medicated creams stored in medicines cupboards and discrepancies in care plans. Medicines incident records did not have enough detail to demonstrate they had been fully investigated and lessons learned shared with staff to reduce the risk of recurrence. Policies in place did not provide sufficient detail about best practice in the management of medicines within the service. For example, the policy did not include clear guidance on the process to follow when adding new medicines to administration records, to limit the risk of errors occurring.

Medicines administration records did not always contain enough information for staff to give medicines as prescribed. For example, 2 people’s medicines had instructions recorded as ‘as directed’. Where medicines were given ‘when required’ (PRN), protocols did not include enough information to guide staff on the dose to administer. Three people were prescribed more than 1 laxative for the relief of constipation; there was insufficient information as to the order in which to administer.

These concerns were discussed with the management team, and we received assurances these concerns would be addressed. We will check for sustained and fully embedded improvement at our next assessment.

Since our last assessment the provider has made improvements in this area. The provider understood their duty to collaborate and work in partnership with others. They shared information and learning with partners and collaborated for improvement.

The provider had developed a service improvement plan and was working with the local authority to ensure improvements were made. This service improvement plan and the completion of actions was an ongoing process. We saw examples of when they had shared information and learning with partners or collaborated for improvement.

The service strived to focus on continuous learning and improvement across the organisation and local system. However, the service provider had not always made enough improvement following our previous inspection and we found some ongoing concerns at this inspection. The manager and senior leaders were working hard to establish a consistent approach to improvement including monitoring progress and outcomes. The provider was responsive to our findings and acted immediately on key areas of improvement.