Blossom 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.

This is the first assessment for this newly registered 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 service was in breach of legal regulation in relation to good governance.

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. We could not be assured staff culture was positive and that staff worked together to provide consistent care, due to a lack of robust care records. Staff had not always received regular supervisions or appraisals, and we received mixed feedback from staff about their work environment and communication between the team and leadership. A staff member said, “The manager isn’t supportive, they don’t do walk rounds. There has been a high staff turnover the past couple of years.”

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. Leaders did not have the skills, knowledge, experience and credibility to lead effectively. We received mixed feedback from staff regarding the leadership, some staff told us the management team were not present around the service. Due to concerns we found relating to people’s safety, the environment and overall governance we could not be assured leaders were effective.

People did not feel they could speak up and that their voice would be heard. We received mixed feedback from staff about if they felt comfortable to raise concerns. Some staff told us they had raised suggestions or asked for things, which had not been listened to. Whilst other staff told us the managers were approachable and they felt they could raise concerns. Staff had the opportunity to attend staff meetings, where key events and issues were discussed. Complaints were effectively managed, and records evidenced some compliments from people and relatives. However, it could not be evidenced what action was taken following feedback from people and relatives. A relative said, “If I had any concerns I would speak to the manager.” Whilst another relative said, “I don’t know how to make a complaint.”

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. We received some concerns relating to staff being treated unfairly and some staff felt senior positions were not fairly recruited. A staff member said, “The manager brings family in.” We found a lack of clinical supervisions for nursing staff, and some staff had not received any supervisions.

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. Governance systems were not effective. For example, audits had not been completed regularly, and where completed, failed to identify issues such as medicines management concerns, records concerns, managing risks posed to people, staffing concerns, and environmental risks. The provider had visited the service regularly, however, audits they completed were vague and did not identify the shortfalls within the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The service worked with external partners. For example, healthcare professionals such as GPs and specialist teams were involved in people’s care. We received positive feedback from partners and professionals visiting the service. A professional told us, “It is nice, staff are friendly. Staff are good at following treatment advice.”

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. Continuous improvement was not embedded. There was no clear quality improvement plan in place to drive sustained improvements. The provider had recently recruited a quality and compliance lead as they had recognised some shortfalls in the service. They planned to implement more robust auditing systems, however these required embedding into practice at the time of our assessment.