Rook 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 registered service. This key question has been rated 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.

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

This service scored 62 (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.

People spoke positively about the culture of the service. One person told us, ‘‘Yes, I like it here. Everything seems to be fine. It’s down to the manager, she keeps everyone happy.’’ Staff reported a culture of collaboration, where they felt listened to and open communication had been encouraged. A staff member said , “Yes, I think it is fair, open, and supportive.”
 

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.

Staff told us that the registered manager and senior staff were supportive and had a visible presence within the service. Staff said they felt able to approach managers with concerns, issues, or requests for support. Staff reported, ‘‘I can approach them with any concerns.’’ and “The registered manager tries to meet your needs, is open to suggestions, and will always try. I know I can call and support will be provided.”
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had policies in place, in line with best-practice guidance, to support freedom to speak up and the management of complaints.

The registered manager reported, “We encourage staff to raise concerns, and everyone is aware of the whistleblowing policy and how to access it.” Whistleblowing policies explain how staff can report concerns safely and confidentially.

Staff told us they were aware of the term ‘freedom to speak up’ and understood what it meant to them. A staff member reported, ‘‘Yes, I know the whistleblowing policy and who to contact if needed.’’

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. Staff received equality training to help them understand protected characteristics, bullying, and harassment. Staff confirmed that the provider supported their requests for flexible working arrangements.

There were policies in place and in-line with current best practice guidance around equality and diversity of the workforce.
 

The provider did not act on the best information about risk, performance and outcomes. The provider’s governance systems for auditing the service were not effective in identifying or addressing areas for improvement to ensure that people were not placed at risk of receiving unsafe and inappropriate care.

The provider’s quality assurance systems had not identified these gaps, showing that its checks and audits had failed to pick up the issues or prompted timely action to address them. There was no effective system of record keeping in place. Care plans and risk assessments were not regularly updated to reflect changes in people’s health needs, which may impact the quality and continuity of care. Regular staff supervision, spot checks and appraisals were required to ensure staff have the skills and knowledge needed to provide safe care.

There was no effective system of record keeping in place. Care plans and risk assessments were not regularly updated to reflect changes in people’s health needs, which may impact the quality and continuity of care.

The system for obtaining and recording consent was not effective. Care plans and review forms did not always include signatures to evidence people's consent, involvement, and agreement with decisions about their care and support.

However, the provider had a business continuity plan in place to help ensure the service could continue running during and after any significant disruptions.

We have asked the provider for an action plan in response to the concerns found at this assessment.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

They shared information and learning with partners and collaborated for improvement. The registered manager informed us they regularly engaged the provider forum to support service development and to achieve improved outcomes for people. The registered manager told us, "We attend the local authority provider forum. Last year, we also attended the CQC registered managers' forum."
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation. They did not always encourage new ways of improving people's quality of life and outcomes. The provider did not always actively support safe, effective practice and research.

However, provider actively sought the views of staff, people using the service, and their relatives and carers when developing and evaluating improvement to ensure there was a culture of continuous improvement. Staff viewed learning from incidents and accidents as an opportunity to improve the service.