Filsham 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 Requires Improvement. At this assessment the rating has remained Requires Improvement.

The provider was previously in breach of the legal regulation in relation to governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

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 which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

There were on-going concerns across the service and the culture of the service had not always promoted people’s safety on the delivery of consistent good care.

The staff team told us they had worked hard to improve the service but had not been adequately supported to make and sustain improvements. The registered manager spoke of the plans to improve and felt that they had been making slow progress, but recent events had impacted negatively on improvement.

Leaders had not ensured there was a shared vision and strategy and that staff in all areas knew, understood and supported the vision, values and strategic goals and how their role helps in achieving them. The provider had not made improvements since the last inspection, the environment and cleanliness of the premises was still in need of immediate action. The documentation for people whilst improved, still had shortfalls that meant not all staff had the relevant information and directives to provide consistent safe care.

People and relatives were mostly complimentary about the culture in the service. One person did say that she never saw the manager or someone senior, but all other comments were positive, including, “They treat you as a person they do not speak down to you just because you are older. They are not condescending and they let me do what I want. I don’t want to mix downstairs so they let me stay up here and treat you as an adult.” One visitor said, “I can just pop in to see X(manager) always welcoming and very knowledgeable and kind.”

Staff spoke positively about the registered manager and told us they felt able to ask for support if needed. One staff member told us, “The registered manager has an open door policy, she will make time for us.”

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. Despite the open and honest attitude of the registered manager several staff told us they had felt let down and not fully supported through recent events and for the needed improvements to the premises. One staff member said, “We have been promised new equipment, furniture and better maintenance, but it never seems to happen until it has to be.”

The service comprised of two different units supporting people with specific needs, however floor leadership was not consistent as they did not have dedicated staff on each unit. The registered manager wanted to create teams for each unit with a senior nurse, registered nurses team leaders and care staff so this will empower staff and increase staff knowledge of the people they support and there would be accountability at all levels.

There were systems and processes in place to support staff development and progression within their roles. Staff talked of how they were supported to gain qualifications and extend their role, for example, becoming a senior. Senior care staff were supported to be become medicine givers and received support and training. Staff received regular supervisions, spot checks, competencies and values-based supervisions took place. The provider’s senior management visited the home regularly and provided support and supervision to the registered manager. The registered manager told us she attended organisational manager meetings which enabled learning across the organisation to be shared and relevant lessons learnt implemented within the home.

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

Staff told us they were happy to raise concerns with the registered manager, and they were confident these would be looked into. Where necessary, concerns would be treated confidentially. The service had a complaints policy in place, which listed the process of how complaints could be made, and what they should expect. The policy also listed a range of services staff could complain to outside of the service if they felt the need to do this. People and their relatives told us they were able to contact the registered manager to raise concerns if required. We viewed recent complaints and the initial actions taken.

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. Several members of staff had worked at the service for over 5 years. Staff retention reflected their satisfaction at working at the service over time, despite the recent changes. Different cultures and religions were represented within the workforce and staff told us that any requests for changes in shift or days off due to different cultural celebrations had been supported by managers. Equal opportunities and equality and diversity policies were in place and reviewed regularly.

The provider 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.

There was no evidence to suggest that learning from accidents and incidents whether positive or negative had been recorded and shared with staff. Some people had experienced several falls and although these had been recorded, there was no analysis of when or where or what had caused the falls. There was no evidence of a root cause analysis to assist in identifying themes and trends. This had meant no preventative measures had been put in place and no reduction in falls. Other professionals had raised safeguarding investigations in relation to falls at the service and these are currently in an organisational safeguarding.

There was a quality assurance framework in place, however these were not effective as they had not identified the shortfalls we found regarding infection control, maintenance of the premises, and shortfalls in care documentation and risk assessments. Previous issues at the inspection in February 2024 had not been resolved and remained outstanding.

There was a lack of oversight in certain areas, for example, the management of distressed behaviours, and the use of medication to manage these behaviours. This was because the documentation completed by staff did not always reflect the use of de-escalation techniques and the effect of these techniques before administering medication. There was a lack of overview of peoples’ weights where weight loss was identified, but despite showing some people had weight loss of up to 9 kgs was not reviewed but thought to be an equipment failure. This was not recorded however and therefore weight loss was not being fully monitored and there was a risk of undetected weight loss and gain.

Some people who had been assessed as being at risk of choking and had been under the care of specialist team, did not have a risk assessment in place and in May 2025 had a choking event. No follow up was recorded within the care plan. This placed the person at continued risk. This has now been referred to the SaLT team for advice.

We are aware of feedback from health professionals where they have identified concerns regarding poor communication, poor management of medicine, lack of personal care of people, poor management of clinical emergencies, and concerns regarding the environment. Some of these are currently in the organisational safeguards and changes were being made. Meetings between external health professionals and the home management team have been planned to ensure that communication continues to improve and therefore improve partnership working and outcomes for people.

Staff were not clear on their roles and responsibilities within the service. Clarification of certain tasks between housekeeping and care staff was needed as was who was responsible for care plans. For example, we asked staff who was responsible for the cleaning of sluices and we got differing answers. Nurses were not sure yet of who was responsible for care plans and this will be discussed at next staff meeting.

Complaints were responded to appropriately, actions recorded as to how it was responded to initially, however there was no further evidence of steps to monitor and resolve. For example, two complaints were around missing clothing, but apart from clothing found there was no plan of how to prevent clothing missing in future.

Relatives did tell us they were kept informed following a fall or any other incident involving their loved ones.

The provider shared information and learning with partners and collaborated for improvement. However, there was evidence that this was not always done in a timely way. This pertains to repeated falls, behaviours that distress and swallowing difficulties.

Staff and leaders told us they worked in partnership with key organisations to support care provision, service development and joined-up care. Staff worked with various external agencies including, GPs, community mental health teams, Tissue viability nurses, social workers, and local authorities. Staff told us how they would contact relevant external professionals to meet people’s needs. The staff team told of how they made referrals, and we saw information in care plans to reflect this.

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.

Due to the lack of outcomes of auditing and quality monitoring processes there was no record of learning lessons from when things go wrong. Lack of management oversight meant that longer term trends were not captured. Accidents and incidents were recorded and then discussed at handover or staff meetings’ but there were no written record of the outcomes of these conversations. When incidents were recorded on the computer system there was no record of actions taken and preventative measures.