The 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 the legal regulation in relation to the governance and oversight at this service.
 

This service scored 54 (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 always have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people.

Leaders demonstrated commitment to improving the service and had taken action following the last inspection. Staff described supportive leadership and improving communication. However, these improvements were not yet consistently reflected across all areas of practice, particularly governance systems.

We found some indicators of a closed culture forming, where people and professionals did not always feel confident to raise concerns directly to senior managers. Although this was a minority, it identified improvements were needed. A professional described the management approach as, “Not always receptive to feedback. “

Although some staff described a supportive team culture, some feedback was not consistent with this and did not translate into an open and transparent culture. We discussed further work was needed to improve in this area and the management team were keen to appear more open and visible within the service.
 

Leaders had some knowledge of the service and demonstrated commitment to improvement; however, this was not consistently reflected in effective leadership or outcomes.

The registered manager described actions taken since the last inspection, including environmental improvements and increased oversight. The manager told us they had been, “Working through an action plan to improve things,” demonstrating intent to improve. However, these actions had not resulted in sustained or embedded improvements. Risks identified at the previous inspection, particularly in medicines, care planning and governance, remained evident.

Feedback from staff and professionals was mixed. While some staff felt supported by leadership, others described inconsistencies in communication and responsiveness. Leaders had not consistently demonstrated the capability to embed improvements or ensure safe, high-quality care.
 

The provider had systems in place to support people, relatives and staff to raise concerns and share feedback, and these were generally understood and used.

The majority of staff described a culture where they felt able to speak up, with one stating they could raise issues and, “They would be acted upon,” demonstrating confidence that concerns were taken seriously. However, some staff did not feel able to do this. A staff member reflected this inconsistency, stating, “Sometimes things get listened to, sometimes they don’t,” indicating a lack of reliable response to concerns.

Relatives and professionals reported improvements in openness and communication. There was evidence the provider was taking steps to strengthen engagement, including increasing the visibility of leaders and introducing additional ways for people, professionals and staff to share feedback. This supported a more open approach and encouraged greater involvement in the service.

Leaders responded positively to feedback and were working to build trust and transparency across the service.
 

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.

Staff spoke positively about team relationships and support from colleagues. A staff member told us, “We all get on, everyone’s treated the same.” Equality, Diversity and Inclusion (EDI) Policies were in place and staff received regular EDI training.
 

The provider did not always have good effective governance systems in place. They did not always include the best information to be able to evidence positive outcomes to drive improvements across the service.

At the last inspection, the provider was in breach of the legal regulation in relation to good governance. Auditing systems which failed to identify risks at our previous inspection, had been improved but required further time to evidence consistent and sustainable improvements across the service.

Audits, monitoring processes and regular reviews were undertaken, and leaders demonstrated oversight of the service. There was evidence of a range of audit tools being used to review care delivery, safety and quality. The registered manager advised, “We complete audits regularly.” However, some of these audits had not been effective in identifying issues we found during this inspection, including gaps in care planning, medicines monitoring and record keeping. Records were not consistently accurate, complete or up to date, which limited oversight and the ability to monitor care effectively. This required further work to ensure all auditing systems continued to sustain improvements across the service.
 

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 provider worked with external partners to support people’s care; however, this was not always consistent or effective. There had been some recent improvements in working with healthcare professionals, particularly district nurses. However, feedback from other professionals indicated that collaboration remained inconsistent.

Recommendations from external professionals were not always acted upon, which impacted on the effectiveness of partnership working. A professional told us, “They do contact us, but not everything gets followed through,” highlighting inconsistency in collaborative working. Although partnerships were in place they were not consistently effective in ensuring positive outcomes for people.
 

Leaders had implemented changes following previous breaches, including improvements to risk management and medicines systems. However, improvements had not been consistently embedded or sustained. Systems for continuous improvement were still developing and required strengthening to ensure lasting change.

While people experienced kind and responsive care, this was not consistently supported by effective recording systems. The provider was working to continue improving the service, and showed a commitment to be more open, and responsive in terms of engagement and activities. They advised a new digital system was being rolled out to improve more detailed and personalised care planning with input from care staff.

A member of the management team acknowledged challenges, stating, “We’ve still got more to do.” The management team reflected a willingness to learn and improve the service further and had taken steps during this inspection to introduce further oversight in order to embed effective improvements across the service. These included suggestions boxes, revised surveys for relatives and professionals and other work.