Rectory 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 changed to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 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 and their communities.

Since our last assessment, a new registered manager had been recruited and feedback from staff was mixed about the changes the new manager had brought to Rectory Lodge. Some staff told us they felt there was a divide between the staffing team and this was impacting on the culture within the service. Some comments included, “There is a divide at the moment which is impacting morale” however other comments were positive about the morale, “Morale is good, but some shifts run better than others.” The new manager told us that there had been some challenges with changing the culture at Rectory Lodge and this was an ongoing process and it will take time to further embed changes to improve the culture in the home.

Staff with extra responsibilities told us they had been supported with additional training and encouraged to expand and utilise their skills and knowledge. Comments included, “I have got support to progress now” and “I feel supported.”

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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The provider had recently recruited a new manager who was still embedding changes and improvements to Rectory Lodge, including making significant changes to improve the service as a result of our previous assessment. The management team were responsive, open and honest throughout the assessment and responded positively to feedback given.

The provider had policies and procedures in place that supported staff with speaking up such as a safeguarding and whistleblowing policy.

Since our last assessment there had been an increase in the number of supervisions being carried out and staff told us they had been receiving supervisions which they found supportive. Comments included, “Supervisions are ok, I can express what I feel, if goals are not met, we can discuss why.” The new registered manager told us they were reintroducing appraisals and introducing continuous professional development (CPD) logs for staff development.

There were regular meetings with people, but it still needed to be clearer around how feedback was being actioned and how often there was engagement with representatives.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The provider had a policy in place for equality, diversity and inclusion. Staff had completed training in equality and diversity.

Feedback from staff was mostly positive about being treated fairly at work and staff told us they felt that any concerns they raised would be acted on. We observed a positive culture during our onsite inspection.

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.

Processes to monitor the quality of the service had been increased and improved since our last assessment. The new registered manager had introduced and implemented new audit processes, including a weekly medication audit, more robust fire audits and lessons learned around accidents and incidents.

At our last assessment we found the provider’s processes for reporting safeguards and notifying CQC were not robust, and the provider had failed to report notifiable incidents. At this assessment we found this had improved. Processes in place to monitor the environment were more robust, and we saw evidence of more regular reviews of care plans and risk assessments, however there were still some areas of improvement required around the key worker system, ensuring all areas of people’s care plans contained the relevant information and documentation of MCA’s and Best Interest decisions.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The provider had processes in place to ensure people had access to external health professionals. They ensured information was shared with partners to help improve outcomes for people. This had improved since our last assessment.

People were being encouraged to access the community more and there had been an increase in activities around the service. One person told us, “I like to go clothes shopping, to get my hair cut and to the café and staff support me to do this.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider had acknowledged at our last assessment that improvements were needed to make sure people always received high quality care and support. At this assessment we found the provider had continued to take their learning from their involvement with the local authority and learning from our previous assessment to make improvements to the service.

The provider had implemented new audit processes and moved to an electronic care planning system, which meant they had better oversight of trends and outcomes. The new registered manager was also in the process of developing further audit processes to further embed continuous learning, innovation and improvement across the organisation and local system.