Weaver 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

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 inspection we rated this key question good.  At this inspection the rating has remained as good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We scored the service as 3. The evidence showed a good standard. The service 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.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. The service model established the culture of Weaver Lodge, focusing on patient needs, strong relationships and valuing lived experiences. 

Staff had the opportunity to contribute to discussions about the strategy for their service, staff we spoke with gave examples of where they had made suggestions for improvements. This included changes to the security booklet, and introducing ‘care plan of the day’ to encourage people to review care plans regularly. 

Staff were proud of the work they did in the service; they were knowledgeable about the patients, and focused on making improvements, and increasing the offer of activities within the service. 

The service had a new registered manager, who had been at the service for around 6 months. Prior to this new manager there were issues at the service around the stability of leadership and culture, which impacted on staff turnover. Staff we spoke with were very positive about the new manager and the changes they were making to the service. 

We scored the service as 3. The evidence showed a good standard. The service 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.

Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the service they managed, as well as the patients within it. Managers were aware of the areas in the service that required improvements and worked with leaders and staff to address these areas. They could clearly explain how the team were working to provide high-quality care.

Leaders were visible in the service and patients we spoke with felt that they were approachable. Staff we talked with spoke highly of the new management within the service, the stability they had brought to the service and the improvements they were making. 

Leadership from the wider organisation were also visible, through ‘uMatter Walkabout’, where senior leaders from the provider would meet staff and patients to gather feedback on the service. 

Leadership development opportunities were available, including opportunities for staff. Some staff we spoke with had been offered the opportunity to complete their nursing training, and other members of the nursing staff had completed it with the support of the provider. 

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The provider completed an annual survey of families, carers and patients, which was collated against the provider as whole, and on an individual service level. The survey provided positive feedback from patients who felt they could raise concerns and felt supported. It also highlighted areas for improvement including patient involvement, choice and co-production. To address this, the service had increased patient participation in MDT meetings and strengthened patient involvement through regular community meetings. 

The service had also had a Culture Review, where provider representatives worked with staff to review culture, highlight themes and potential areas for improvement. The review highlighted areas of improvement around confidentiality, handovers, support for staff after significant events, and professional relationships between staff. For example, managers were asked to consider reinforcing expectations and ensuring a respectful professional environment. The review also noted that the new management team had made significant cultural improvements, which we saw reflected in staff meetings, and feedback from staff. This included staff being supported following significant events, and a greater focus on staff wellbeing.  

We scored the service as 3. The evidence showed a good standard. The service 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 were able to apply to work flexibly with flexible working agreements to support personal circumstances such as caring responsibilities and health issues. For example, within the service there were staff who worked short days. Managers put reasonable adjustments in place for staff members to help them carry out their role.

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. Managers had access to monthly Equality, Diversity and Inclusion (EDI) data reports which included an overview of workforce declarations relating to protected characteristics and analysis of EDI data to monitor representation across protected characteristics, identify trends, highlight any disparities or potential inequalities. These reports were monitored to identify potential inequalities or under representation, to develop appropriate actions in recruitment, staff engagement and policy review. 

We scored the service as 2. The evidence showed some shortfalls. The service 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.

There was a clear framework of what must be discussed at team or directorate level meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. The service had an action plan in place following a serious incident that occurred within the service. The actions covered a variety of areas including medication safety, workforce and capacity, staff wellbeing, clinical governance and professional standards. Almost all actions had been completed, with the final action being dependent on the onboarding process for a senior nurse practitioner. 

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. Regular monthly care record audits were conducted, which identified areas that required improvement, such as Know Your Patient documentation, patient safety plans, and mental health outcome assessments. Following each audit, individual action plans were created for the nursing team to address gaps in records, and where learning was identified, staff were supported by the service’s senior nursing practitioner to provide supportive improvement. However, during the inspection we found that crisis plans were not always in place for patient who had an identified need in their risk assessment and in 1 care record, we found the patient did not have a risk assessment in place, despite the risk being identified 4 weeks before in an MDT meeting. This was addressed during the inspection, and a risk assessment was put in place. 

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

The service had a risk register in place, which identified risks with a red, amber, green (RAG), controls in place to mitigate risks, and what further actions were required. One item on the risk plan was the fire alarm system, during our inspection, work was being carried out to make improvements, managers ensured that staff and patients were aware of the work and could access support if required. Staff concerns matched those on the risk register. The service also had maintenance action plans in place to address the areas in the service that required improvements. 

The service had plans for emergencies for example, adverse weather or flooding or fire within the service. The plan provided detailed information to identify emergency equipment, an overview of patients with a Personal Emergency Evacuation Plan (PEEP), and guidance for different emergency procedures to support staff should they occur. 

The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff, and team managers had access to the information they required to perform their role. This included information on the performance of the service, staffing and patient care. Information governance systems included confidentiality of patient records.

Staff had access to the equipment they required. However, the service had recently introduced a new electronic record system, which was difficult to navigate as documents were not consistently saved in the same place. The system also lacked archiving, which meant it was not clear when items had been updated, either formally following an MDT meeting or informal changes made by staff. The system was in its first phase of implementation, and staff had raised suggestions for improvement. To support senior staff with an overview of the care records, there was a checklist to ensure tasks were completed on admission and repeated as required such as 4, 8 or 12 weekly. These included START, safety plans, and patient weight.

We scored the service as 3. The evidence showed a good standard. The service 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.

Leaders engaged with external stakeholders such as commissioners. The service worked with the local mental health Trust which commissioned beds to address where there were gaps in care, such as care co-ordinators not attending MDT meetings. The commissioning Trust also completed regular quality visits. When actions had been identified managers at Weaver Lodge worked to address them. For example, creating a clear register of external professionals involved in each patient’s care and continuing to audit the effectiveness of the ongoing improvement project. 

Through the provider, the service had a co-production action plan. This included developing a People’s Council, which Weaver Lodge were currently looking to source a representative for. There was also work being undertaken to recruit patients as new members to co-production groups. The provider was currently in their second year of co-production projects. 

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff were given the time and support to be involved with improvements and innovation in the service and this led to changes. Weaver Lodge had a quality improvement project in place, ‘Triangulation of Documentation’ which had expanded across the provider. The aim of the Triangulation of Documentation project was to improve the quality, consistency, and evidencing of nursing documentation, through ensuring that all clinical documentation provided consistent information about the patient. To ensure this, a 5-step model was developed: assess it, plan it, do it, record it, show it works, with a clear expectation of how records and evidence of what doing these steps well should look like. The project had a 12-week timescale, with the aim of the final audit to be above or equal to 80%. The project was developed alongside staff, with training and workshop sessions with staff, that sought to ensure staff understood the training, and how it could be improved. 

Innovations were taking place in the service. The service had also introduced ‘Independence Goals’, which encouraged staff to focus on enabling patients to achieve goals, through fostering a holistic, person-centred approach, building skills and reducing the reliance on support. The service had introduced a nursing associate programme to strengthen the nursing team by increasing clinical capacity and help improve the continuity of care. 

The service also participated in the Accreditation for Inpatient Mental Health Services (AIMS) Rehabilitation Developmental Peer Review, which provided the service with the opportunity to reflect on current practice, recognise areas of good practice and identify where further improvements can be made.