Cheybassa Lodge Rest 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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of legal regulation in relation to the governance of the service.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Although the nominated individual and registered manager recognised a poor culture at Cheybassa Lodge Rest Home, improvements had not been sufficiently made at the time of our inspection. People received care that did not effectively meet their needs and were at increased risk of harm.

The culture of the home was not person-centred. There were instances where people’s care needs were not met in line with their needs and preferences. Staff were very busy, and task orientated leaving little time to sit and engage with people. People were not always included in decisions about their care, and their independence was not always promoted. The nominated individual and registered manager told us they would continue to work on improving the culture.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation.

At the time of our inspection the service was not well led. The registered manager was on leave, and the nominated individual told us some documents were held on their computer which no one else had access to. The provider was also in the process of changing some systems from paper to electronic which caused some confusion. Therefore, we could not gain sufficient access to the necessary assurances, evidence and documentation in relation to managing the service during this time. We were additionally concerned there was not anyone with the skills or experience to assess, monitor and mitigate the quality and safety of the service.

The nominated individual told us the previous manager had not managed the service well and felt this was largely the reason for the issues in the home. However, the provider had run the service for 2 years and had not met their responsibilities to ensure people received safe, effective, compassionate and high-quality care.

The nominated individual had become more involved in the service, and a new registered manager had been in post for approximately 3 months, and staff were positive about them. Time was needed to embed any changes they had implemented.

People did not always feel they could speak up and that their voice would be heard.

Where people had spoken up and reported concerns, these were not always accurately recorded, and there was not always evidence of a clear investigation into the issues raised. For example, 1 person was highly anxious about another person entering other people’s bedrooms and harming staff. Although the nominated individual was aware of some of these issues, they did not have knowledge of the extent of them and the impact this had on people and staff. This meant concerns had not always been taken forward, leaving people at risk of harm and without assurance their voices were valued or their concerns acted upon.Other people told us the staff were approachable and would talk to them if they had any problems. They described the staff as kind and willing to help.

Staff told us they were confident to raise issues with leaders, and some had begun to do so. However, other staff had not identified areas that should be raised such as concerns about people’s distressed emotions and recording issues. This increased the risk of poor practice continuing. This showed time was needed to embed changes.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider employed a diverse workforce. Some staff had been working at the home on sponsorship from abroad. There was no evidence these staff had received specific support or training to ensure they could meet the needs of the people living in the home. One staff member’s record demonstrated they had not received an effective induction. Despite this, all staff told us everyone was treated equally and fairly without discrimination.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Systems and processes were not operated effectively to ensure the service was safe and people were receiving high-quality care. This led to multiple breaches of regulation and placed people at risk of harm and abuse.

The concerns found at the inspection included but were not limited to, risk and medicines management, staffing, consent, the environment and supporting people in a dignified and person-centred way.

There was a lack of quality assurance systems to ensure adequate oversight of the running of the home. Audits and other checks were either not taking place or showed significant gaps. Where issues had been identified in audits, action was not taken to ensure the necessary improvement. The provider did not have systems of governance in place to ensure risks to people had been reduced. This meant people were at risk of harm.

Records were not always detailed and up to date. For example, care plans were not detailed enough for people to receive person-centred care. Records relating to the management of the home were additionally not in place or incomplete. These included records relating to recruitment, and the management of the environment. The provider was using a new electronic care planning system. We found these records were not always reflective of care practice. This meant care could not be adequately monitored.

The provider had failed to ensure that notifiable safety events were reported to the Commission as required. This included a safeguarding raised by a professional external to the service and altercations between people. This demonstrated a lack of effective oversight and governance in ensuring statutory reporting duties were met.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people.

Whilst the provider was improving working in partnership with other health and social care partner agencies, they did not work closely with community and leisure groups. This left some people isolated from taking an active part in their local community.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

There was no effective process for improving the quality of care for people. Staff did not benefit from frequent structured supervision, feedback or lessons learned discussion. This would support staff to reflect on practice and to develop and embed their approach to providing person centred care.

Although the provider had an action plan in place this did not identify all the concerns we did and did not drive the necessary improvement. Audits were not used effectively and if issues had been identified, action had not been appropriately taken to resolve them.

The local authority had implemented resources to support the provider, and they were engaging with these. The registered manager was working hard to make improvements, but the systems implemented were too early to demonstrate compliance. Time and support were needed to continue and embed improvement