South Moor Lodge Care 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

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 good. At this assessment the rating has remained 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 75 (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’s vision focused on providing people with ‘the highest standards of care’. They had a set of values which were shared with staff and included, ‘to provide a homely place for our residents to live’. The registered manager and staff provided people with care which reflected that vision and was person-centred, safe and reflected what was important to people and their families. They ensured staff provided kind, compassionate care in a comfortable environment. One person told us, “I think they [staff] are all very nice and helpful. There’s a nice atmosphere here.” A relative commented, "It’s very nice. They are nice to [family member] and make us feel very welcome. They let us know how she has been.”

The registered manager ensured staff were clear about their responsibilities and the provider’s vision. A staff member told us, “The culture here is to provide people with kind, caring, compassionate care.”

The registered manager possessed the knowledge, skills and experience necessary to manage the service well and ensure staff provided people with a high standard of care which reflected the provider’s vision. They stayed up to date with good practice through regular training, reflective practice and by networking with other professionals. A staff member told us, “The culture of this organisation is open, honest and supportive. [Registered manager] creates that.”

People and relatives were happy with how the service was being managed. They told us, “I know the manager, she is more like a friend. She definitely listens and has sorted things out for me” and “I have met [registered manager] when we came here. She is very nice and approachable and seems to know what she is doing.”

The registered manager and provider ensured staff completed the induction and training necessary to meet people needs and provide them with compassionate care.

The provider and registered manager created a positive culture where people felt they could speak up and they would be listened to. People and relatives were encouraged to raise any concerns about the service during regular meetings and reviews. They found the registered manager approachable and told us they felt able to raise any concerns. No one we spoke with had complained about the service.

Staff felt able to raise concerns with the registered manager or deputy manager and felt confident they would be listened to and any concerns would be acted upon. They were aware of agencies they could contact, such as the local authority or CQC, if they wanted to raise issues externally.

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

The staff we spoke with were happy working at the service. They felt valued and fairly treated and told us they could raise any concerns with senior staff or the registered manager. We noted the service employed internationally recruited staff, but we did not receive feedback from them as part of the assessment.

Staff were able to raise concerns and make suggestions at regular meetings, supervisions and through feedback questionnaires. Records showed when concerns were raised or areas for improvement identified by staff, the registered manager considered and addressed them.

Governance arrangements at the service were effective and ensured people received safe, compassionate care which reflected their needs and risks.

The registered manager and provider ensured regular checks and audits were completed, including those related to medicines, infection control, care documentation and the environment. The audits completed ensured appropriate standards of quality and safety were maintained. Action was taken or action plans were in place to address any shortfalls found. We noted a small number of the audits we reviewed lacked detail, such as who had completed them and when. We raised this with the registered manager and provider.

The registered manager ensured staff had the knowledge, skills and abilities to provide people with safe, effective care. Staff performance was reviewed regularly and where any shortfalls were identified, prompt action was taken so that the required improvements were made.

The provider worked in partnership with other agencies, so services worked seamlessly for people. The registered manager and staff worked well with partner agencies, such as GPs and community nurses, to ensure people received the care and treatment they needed to meet their needs and experience a good quality of life. Staff attended a weekly GP review where concerns about people’s health and wellbeing could be discussed and any investigations or treatment arranged. In addition, referrals were made to a variety of community services, including physiotherapy, speech and language therapy and the tissue viability service, for specialist support when needed.

Where investigations or ongoing treatment took place, the registered manager and staff collaborated with partner agencies, providing updates and identifying concerns or improvements. This helped to ensure people’s health and wellbeing was monitored; action was taken when there were any changes and they were provided with a seamless service. Any learning and updates were shared with partners to improve people’s outcomes. A community professional who visited the service told us staff provided appropriate care and were knowledgeable about people’s risks and support needs.

The provider focused on continuous learning and improvement, to deliver equality of experience, outcomes and quality of life for people.The registered manager and staff provided people with person-centred care and worked well with partner agencies to meet people’s needs and gave them a good quality of life. Staff followed advice and guidance provided by partner agencies, to ensure their practice and the care provided was safe and effective and resulted in good outcomes for people.

The provider and registered manager embraced opportunities to improve and develop the service. The registered manager reviewed incidents, accidents, complaints, safeguarding concerns, audits and feedback received, to identify learning and opportunities for improvement. They received regular updates from CQC, the National Institute for Health and Care Excellence (NICE) and local health and social care authorities, which enabled them to remain up to date with regulations, guidance and best practice. They encouraged an open culture where staff could raise concerns and share ideas, which helped support continuous improvement.

The provider had ongoing projects related to areas they had identified needed improvement. These included, making care plans more person-centred, improving staff awareness about the Mental Capacity Act and strengthening and standardising how staff reported and recorded accidents and incidents to improve learning. This demonstrated the provider’s proactive learning culture and focus on improvement.