Park Lodge Residential 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

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 changed to requires improvement.

This meant the service 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 good governance.

This service scored 54 (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 clear shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

There was a lack of effective oversight by the provider to ensure people’s needs were met in accordance with their care plans and that people received meaningful, individualised support. The provider and management team did not demonstrate effective oversight of staff practice or ensure identified risks were consistently assessed and managed.

Audits and monitoring systems were not effective in identifying the shortfalls found during this inspection. This meant the provider could not be assured that risks to people’s safety and wellbeing were identified and addressed promptly or that people consistently received the care and support they required.

The provider was responsive to concerns raised during the inspection and took action to address some of the shortfalls identified. However, their approach had not been sufficiently proactive, as their own governance and monitoring systems had not identified a number of concerns relating to care delivery and record keeping. Improvements needed to be embedded into practice and sustained.

Staff told us they felt listened to and were able to provide feedback to the management team.

Leaders were caring and approachable; however, they did not always demonstrate the capability and effective oversight required to ensure people received consistently safe and good-quality care.

People and their relatives were complimentary about the management of the service and described the manager as caring and approachable. A person said, “The manager is brilliant, I couldn’t say enough about her. You couldn’t have a better manager, she is caring.” A relative said, “I have no complaints about the manager who cares greatly about the welfare of the residents and is very approachable.”

However, despite this positive feedback, we identified significant shortfalls in the oversight and management of the service. Systems and processes had not been effective in identifying and addressing a number of concerns relating to people’s safety, care and record keeping. This meant leaders could not demonstrate that they had effective oversight of the quality and safety of the care people received.

The registered manager left their role during the inspection. The provider had put interim management arrangements in place and was recruiting a new registered manager. The provider was responsive to concerns raised during the inspection and began taking action to address the shortfalls identified. However, improvements needed to be embedded and sustained to demonstrate consistently effective leadership and oversight.

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

Staff knew how to report concerns with the provider and to external organisations, such as CQC and the local authority if necessary.One staff member said, “There is an adult safeguarding sign that I can use.” Another staff member told us, “I feel comfortable speaking up if I have a concern. Working in care, we sometimes see things that need to be raised, and I believe it is better to speak up than keep something to yourself. If I am concerned about a resident, their care or something happening at work, I would speak to the manager and follow the correct procedure. I feel that staff should be able to raise concerns without feeling that they will be judged for doing so.”

The provider had an up-to-date safeguarding policy. However this was not available to staff at the time of the inspection. The provider told us they will ensure the policies are accessible to all staff.

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

Staff told us they enjoyed working at the service and felt supported.A staff member said, “I feel the workplace is inclusive. Staff come from different backgrounds and work together as a team. I feel that people are treated fairly and are given the opportunity to raise their views and concerns.”

New staff completed a health questionnaire form as part of the application process. This enabled the provider to identify whether any reasonable adjustments were required to support staff to perform their role effectively and safely.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. Systems did not enable the provider to consistently identify, assess, monitor and mitigate risks to people or identify and address shortfalls in the quality and safety of the service. This resulted in widespread and significant shortfalls and meant the provider could not be assured people were receiving consistently safe and good-quality care.

The provider did not have effective oversight of the service. Governance systems in place were ineffective and did not identify shortfalls found at this inspection. This put people at risk of harm.

Records relating to people's care were not always accurate, complete or person-centred. Care plans were held in paper folders and were available to staff; however, some contained handwritten information which had not been recorded in the appropriate sections. For example, 1 person's care plan stated that records of meetings with external professionals were held on an electronic system which was no longer in use. Handwritten information relating to the person's recent involvement with professionals and deterioration in their health had instead been recorded within their health history, a section intended to record health conditions. This meant important information about people's changing needs was not consistently recorded in a clear and accessible way. The provider's systems had not identified or addressed these record-keeping shortfalls, increasing the risk staff would not have the accurate and up-to-date information required to provide appropriate care.

There was not consistent management oversight of incidents and accidents. Although the provider had a system intended to identify themes and trends through monthly reviews of incident records, this was not consistently used. This limited the provider's ability to identify emerging risks, learn from incidents and take action to reduce the likelihood of recurrence.

The provider did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Staff understood their responsibility to collaborate with health and social care professionals. Staff told us they contacted external professionals when people required additional support, and records confirmed that communication with professionals took place.

However, systems for recording and maintaining information received from external professionals were not always effective. For example, information relating to 1 person's recent involvement with external professionals and deterioration in their health had been handwritten within the health history section of their care plan. Other information referred staff to an electronic system which was no longer in use. This meant there was a risk that important information shared by professionals was not readily available to staff or used consistently to inform people's care and support.

Records of communication with external professionals were not always sufficiently detailed to demonstrate what information had been shared, the advice provided, or whether any required actions had been completed. This limited the provider's ability to demonstrate that people's care remained coordinated when different services were involved.

A health and social care professional said, “From what I've seen during my visits I have no concerns but feel if I had any the management and staff would be very responsive.”

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 did not always demonstrate a clear understanding of how to drive and sustain improvements within the service.

Our inspection found widespread shortfalls which were not identified or addressed through the provider’s quality management systems. For example, people’s daily notes were reviewed, however some trends and themes had not been identified by the provider.

The provider was responsive during our inspection and started to make changes to their systems and processes. However, these were new systems and processes which needed time to be embedded and sustained.