Devonshire House and 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.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant the service was now well-managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 64 (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.

The management of the service were developing a new vision and culture for the staff team and service approach to work together to deliver the best outcomes possible for people using the service. Staff commented the management of the service had an improved approach after recent changes.

One staff member said, “Honestly, it looks lovely now and you come here (each day) to give good care. I feel there have been lessons learnt from what has happened (with medication administration) and we have (the area manager) coming round ensuring we have read (and understood) all the policies. We have had lessons learnt and (the provider) has been very transparent with families, and they have been very good with duty of candour. I feel medication is being amended and we are all willing to learn.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

There were 2 managers overseeing the service. Both were experienced managers and the deputy manager clinical lead was qualified in nursing. However, the service manager was temporary until such time as a new service manager could be employed and registered with the CQC. The Deputy manager although experienced had only been in this post for a few weeks. The service management team was not yet secure and embedded in their roles.

In addition, a Senior care staff managed each of the residential care units and a qualified nurse managed each of the Nursing units. This ensured there was always an appropriate manager and leader present and responsible for the delivery of care on each unit, to maintain the quality of the care delivered.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff had spoken up during the crisis with medication administration and were listened to. The interim service manager and the deputy manager shared an office and had an ‘open door’ policy to encourage staff to speak openly with them. This helped to ensure any issues for the management of the service or the people they supported were addressed as soon as possible.

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 told us they were working better as a team. Staff members told us how leaders supported them both professionally and personally, creating a positive culture amongst the whole staff team.

We heard sponsored staff from other countries were well supported by the service, and in the administration of the service’s sponsorship license. The management of the service ensured they met with these staff regularly and individually for supervision, to provide them with the support they needed.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Oversight and governance of the service had not taken place effectively and the provider had not ensured the service was always well led. The previous service management had not been effective after the urgent change of pharmacy medication supplier and had allowed the administration of people’s medication to fail. The provider’s Governance systems had not identified the developing medication administration crisis for a period of 4 weeks.

The provider’s representatives were now frequently present in the service, had a full awareness of the quality of care and difficulties presently in the service, and were accountable for ensuring the present quality was maintained and continued to improve. Oversight of the service was now effective, and the day-to-day management of the service was being appropriately supervised. One care staff member said, “(It is) quite positive with (the interim service manager) coming in, I am hoping things will change for the better and I have learnt loads with things I have not been shown before with all the people (from the provider) coming in now.”

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.

The service had always worked well with other teams and services to support people. There had been a trusting relationship between other stakeholders and the service, but this had been damaged by the crisis with medication administration. Other stakeholders such as the commissioning Local Authority were now in a process of rebuilding confidence in the service and provider management of the home.

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, outcomes and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had not learned to identify issues that could develop, such as allowing the administration of medication crisis to develop. However, the provider had since become more involved in the service and was working to ensure it improved.

Care staff continued to receive regular individual supervision. Supervision was a 2 way process enabling the supervisee to also feed back to their supervisor on potential improvements that could be made to the quality of the service.

There was a formal survey system that collected the views of people, their relatives and staff. Resident’s meetings were taking place, but additional relatives and resident’s meetings had been arranged in response to the safeguarding process related to medication administration.