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 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 inadequate. At this assessment the rating has changed to 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.

At the previous assessment the service was in breach of legal regulation in relation to the governance of the service. The provider had made the required improvements and is no longer in breach of these regulations

This service scored 61 (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.

Leaders and all the staff we spoke with demonstrated a commitment to providing person centred, high-quality care. They placed people using the service at the heart of everything they did. An initiative called 'Resident of the day' was in place with the aim to improve the overall experience for people who lived in the home. It meant people’s needs and wishes were reviewed in a holistic way and ensured continuous improvement.

Staff told us they enjoyed their work and were pleased to be able to make a positive difference to people’s lives. One staff member told us,” The service has improved so much in the last few months, I love working here, everyone works together to make the home a friendly and happy place, everyone cares so much.”

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 and registered manager had worked hard to improve the service following our previous inspection. Leaders mostly demonstrated the skills and knowledge needed to lead effectively. Although leaders were responsive when we identified concerns, systems and processes still needed to be embedded to ensure they could identify concerns independently. People and their relatives shared positive feedback about leaders.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had not fully embedded robust systems and processes to consistently, effectively assess, monitor and improve quality and safety.

Although there had been significant improvements since the last inspection, some areas of concern had not been addressed in a timely manner. For example, aspects of people’s medication had not been managed safely, and consent was not always sought by those with the legal authority to do so. The provider did not identify these shortfalls independently and improvements still needed time to embed.

Governance systems around the need for consent and medicines were not yet effective or embedded. This meant people remained exposed to the risk of harm.”

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Staff and leaders spoke of how the service had continuously improved since the last inspection and were proud of the home. They were enthusiastic and committed to making further improvements to the service for the benefit of people using it. Where we raised areas for improvement during this inspection leaders were open to our suggestions and took prompt action.

Leaders shared success stories of how they had supported people to improve their health and wellbeing that positively affected their lives. For example, a person who was cared for in bed had an occupational therapist appointment following the service making a referral for support. This enabled them to get out of bed for a hour a day and spend time with people in a communal area of the home.