Harrier 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 governance at the service.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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. The provider had a clear vision for their services including, ‘We treat everyone as individuals so they can live fulfilling, rewarding and happy lives.’ We found during this assessment that this vision was not put into practice. Staff told us, the service did not have an open culture, and they did not feel listened to. Before the assessment, CQC had been contacted with concerns about changes within the service, from relatives and staff who described a culture of being told what to do rather than being involved in decisions and changes. During our assessment, staff confirmed they did not always feel involved in the service and did not always know about changes until they happened. Staff described how they had not been aware of a new role which had been created and had not had the opportunity to apply for it. We discussed this with the registered manager, who told us the role had been advertised on the provider’s website but could not confirm staff within the service had been told about the role.

Staff meetings were held regularly; however, these had been poorly attended. We discussed with the registered manager about how the meeting minutes were shared amongst staff who were not present. They told us, the minutes were kept in their office and staff could ask to see them, they had not been displayed in the staff area to inform all the staff of what had been discussed.

The service 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, and they did not do so with integrity, openness and honesty. There had been concerns raised before, during and after our assessment about the leadership within the service. People and relatives told us, they rarely saw the registered manager around the service. A person told us, they did not know who the new manager was as they had not introduced themselves, “Never see them around. The last manager was always around, chatting to us, to residents etc.” Another person told us, “There’s a new manager. I’ve only met them a few times. The last manager always came in the mornings to see us and ask us if we were alright. They would join in activities and was always around.”

Staff told us they did not feel supported or listened to. Staff described meetings with the registered manager which had been combative. A staff member told us, they had been invited to a sickness interview with the previous registered manager and had felt supported, but this time they felt they had not been believed about why they had been sick. Staff told us they had offered peer support when they had returned to work following meetings with the registered manager. Other staff described how they did not contact the registered manager as they were not confident, they would be listened to, or the registered manager would respond especially during the weekends or evenings.

Staff, people and relatives were concerned staff had left because of the change in manager. A relative told us, “It seems all the good staff left when they (Home Manager) started. Now the staff keep changing but the residents need the constancy.” We discussed this with the registered manager, who told us, staff had not been managed effectively under the previous manager, and they had to make a lot of changes to improve the service.

People did not feel they could speak up and that their voice would be heard. Before and after the assessment CQC had been contacted by staff anonymously to raise concerns about management style, lack of support and staffing. They had written they had been unable to speak up within the service as they thought they would not be listened to and there may be repercussions. As part of an assessment, inspectors speak to staff about their experience of working at the service. When inspectors approached staff at Harrier Lodge, they were cautious about speaking to CQC. Staff told us they were worried about repercussions if what they said was identified as coming from them. Staff eventually spoke with inspectors after a lot of reassurance about how CQC would use the information.

As part of the assessment an Expert by Experience spoke with people to understand their experience of the service. During their conversations some people were hesitant to criticise the service. A person started to speak about staff leaving and how the service was managed, when asked to expand on their comments they said, “I’m not comfortable discussing this any further.”

A person told us, they had complained, when asked if it had been resolved, “It was resolved more or less but not by who I think it should have been.” Relatives had described how they had raised concerns but had been made to feel as if they were the problem. A relative told us, they had previously felt comfortable to discuss with staff or the previous registered manager any issues. The problems had always been solved quickly working with the previous registered manager, but this was no longer the case. We discussed these comments with the registered manager, they told us, some decisions they had made the relative did not agree with.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff had raised concerns with CQC before the assessment about staff leaving as their working patterns had been changed. Staff in their exit interview had expressed they had to leave as the working pattern agreed with the former registered manager was not going to be continued by the current registered manager. They had felt they had been discriminated against when the change had been made. Another member of staff had left as they could not commit to a new shift pattern, and a compromise could not be reached. Relatives were concerned staff had left due to these issues, comments included, “I know of 3 really good staff that left because of the new manager. [staff member] could only work certain hours, but the new manager refused to let them keep those hours, so the residents have lost a perfectly good member of staff because of it.” We discussed this with the registered manager. They told us, there had previously been a lot of staff sickness and absence, and staff were working a 2-week duty rota, this had caused gaps which needed to be covered by agency. The registered manager said staff had been given 6 weeks’ notice about the changes, and tried to accommodate the units staff worked on, and looked at staff skills. They told us their approach was different to the previous registered manager, but they had tried to be fair.

The service 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. Staff and relatives had raised concerns about the management of the service before the assessment especially around the loss of senior care staff. There had been a high turnover of staff including team leaders, who had been in day-to-day charge of the residential units. Staff told us this role now was often covered by agency staff; they were not confident all incidents and concerns were recorded or raised as they should be.The provider told us accident and incident reports were checked daily, but did not provide evidence of this.Before the assessment, CQC had asked for information about staffing, when concerns had been raised. The registered manager had highlighted there were enough staff according to the dependency calculation.However, they had not identified the risk by not having permanent nurses or team leaders on duty, to make sure systems and processes were followed to keep people safe.

The provider had an audit system in place to check the quality of the service. These had been completed by the deputy and unit manager which had identified concerns. There was an action plan produced each month in response to the findings, these remained at the time of the assessment.

The service did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. People were supported by lifestyle staff who organised activities, these included trips out. However, these had not always been as often as possible due to staffing levels. People had not had the opportunity to form links with local community groups. Staff had referred people to healthcare professionals when needed. A healthcare professional told us they were confident staff asked them to review people appropriately.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. The provider had a system in place to monitor the quality of the service. The audits had identified shortfalls, the service had been placed into the provider’s improvement programme, and an action plan was in place. The registered manager had signed off areas to confirm they had been completed. However, further shortfalls had been identified at this assessment, the quality of the service has deteriorated since our last inspection of the dual registered provider in October 2020.