Devon 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 changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 provider had clear values and objectives which were embedded throughout the service. Policies, procedures and the statement of purpose reflected the provider's vision and values, while governance, management and team meetings included discussions about strategic goals and the delivery of high-quality care. This supported a shared culture focused on delivering person-centred care and achieving positive outcomes for people.

People and those important to them experienced a culture that was open, responsive and centred on their needs. Relatives consistently spoke positively about the service and described trusting staff and leaders. One relative told us, "I suggest it and it is done. I trust them completely," while another said, "This is the first place where I feel [Person] feels at home." This demonstrated the provider's values were reflected in people's experiences of care.

Staff described an inclusive and respectful working environment. One staff member told us, "Very multicultural, different people from different backgrounds, we might have differences, but we generally get on with it." Relatives also described staff as thoughtful, caring and supportive. This demonstrated a positive culture where people, relatives and staff felt valued and respected.

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.

Leaders demonstrated the skills and knowledge required to lead the service and had implemented regular systems to monitor quality and safety. Recruitment records were completed in line with relevant requirements, leaders received ongoing training and support, and audits and spot checks were completed regularly to monitor quality and safety. We also saw evidence leaders acted openly and honestly, including applying the duty of candour when required. This supported a culture of transparency and continuous improvement.

Leaders were visible and accessible within the service. During the inspection, managers completed regular walkarounds and were present within the home, providing guidance and support to staff. Staff told us they felt well supported and could rely on leaders to address concerns. A staff member told us, "If there is a problem, they will always support us till it is sorted," while another described management as "the best I have had." Staff had confidence in leadership and felt supported to provide high-quality care.

Relatives, staff and partners spoke positively about the leadership team. Relatives described managers as approachable, responsive and knowledgeable, with 1 commenting, "The manager is excellent" and another stating, "The manager and deputy now are fantastic." Staff described leaders as supportive role models who had the interests of both people and staff at heart, while a healthcare professional told us management was "very approachable." This demonstrated leaders had developed positive relationships and promoted an inclusive culture that benefitted people using the service.

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

The provider had systems in place to encourage people, relatives and staff to share concerns and feedback. Policies relating to complaints and freedom to speak up were up to date and reflected current best practice guidance. Staff surveys were completed regularly, and records showed the provider developed action plans in response to feedback received. This demonstrated the provider had arrangements to consider concerns and suggestions and use feedback to inform service improvements.

People were supported to express their views and access independent sources of support. Easy-read information about advocacy services and contact details was displayed within the home. We spoke with 1 person who was able to identify a staff member they would speak to if they were worried about something. This meant people were supported to raise concerns and seek support when needed.

Staff described an open and supportive culture where they felt comfortable speaking up. Staff consistently told us they would raise concerns if necessary and felt confident they would be listened to. A staff member told us, "I feel I can raise anything," while another staff member commented, "The management have an open-door policy and they are very approachable." Relatives also told us concerns were taken seriously and acted upon. This demonstrated the provider had created a culture where people felt able to speak up and be heard.

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.

Equality and diversity policies were in place, and staff had completed relevant training. Leaders also made reasonable adjustments for staff where required and encouraged an inclusive working culture where people were treated fairly and with respect.

The provider recognised the importance of supporting staff with their individual circumstances and wellbeing. Staff told us managers were flexible and understanding when they needed support, including for childcare responsibilities, religious observance and personal commitments. One staff member told us annual leave requests linked to their faith were always accommodated where possible. This demonstrated leaders considered individual needs and promoted equality of opportunity.

The provider promoted an inclusive culture where staff from different backgrounds and circumstances felt supported and valued. Staff spoke positively about the flexibility and support they received from managers, describing them as understanding and accommodating. This helped create an inclusive workplace where staff felt valued and supported.

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.

Governance systems had not always been effective at identifying and addressing risks within the service. During the inspection we identified concerns relating to environmental safety, infection prevention and control, and medicines management that had not been fully recognised through existing oversight arrangements. This meant leaders did not always have complete assurance that risks to people's health, safety and wellbeing had been effectively managed.

Quality assurance processes had not consistently identified all areas requiring improvement. Although audits were completed regularly across the service, they had not detected some of the environmental, cleanliness and medicines monitoring concerns identified during the assessment. This demonstrated existing governance arrangements were not always sufficiently robust to identify and respond to emerging risks.

Despite these shortfalls, the provider had established quality assurance systems and responded positively when concerns were identified. Quality review audits were detailed and included measurable actions with target dates, and leaders took prompt action during the inspection to address issues raised. A partner told us, "They have a good oversight of the service as much as they can and they are very responsive." This demonstrated leaders were committed to improvement and acted quickly to reduce risks once concerns were brought to their attention.

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 worked collaboratively with health and social care partners to support positive outcomes for people. Staff maintained effective relationships with professionals involved in people's care and worked together to ensure support remained person centred and responsive to changing needs. This helped ensure care remained coordinated, responsive to changing needs and focused on achieving positive outcomes for people.

People were supported to maintain links with their local communities and take part in activities that reflected their interests. Evidence showed people regularly accessed community opportunities with staff support, helping them remain connected to hobbies, interests and social opportunities. This supported people's wellbeing and reduced the risk of social isolation.

Relatives and professionals spoke positively about the service's partnership working. One relative commented that the service had a "good relationship with local GP," while a healthcare professional told us, "Staff are very good and work in partnership with us to achieve better outcomes for people." The healthcare professional also described staff as welcoming and positive to work with. This demonstrated effective partnership working that enabled people to receive joined-up support and remain connected to their communities.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider had systems in place to promote learning and continuous improvement across its services. Governance and management meetings were used to review incidents, quality assurance findings, learning from external events and opportunities to improve practice. This demonstrated the provider had established arrangements to review information, identify learning and consider opportunities to improve practice.

Learning was shared across the organisation to improve safety and outcomes for people. Records showed urgent safety notices were issued when concerns were identified and shared with all services. Staff were required to read and acknowledge these communications, helping ensure learning was embedded consistently. This reduced the risk of incidents being repeated and supported safer care.

The provider encouraged innovation to improve people's experiences and outcomes. Staff had received specialist training from the Speech and Language Therapy team and were involved in trialling new communication technology. A partner described the trial of a high-tech communication device and told us it could "really impact on people positively" if implemented more widely. This demonstrated the provider was exploring new ways to support people's communication and independence.

Relatives and staff reported improvements had been made over time. Relatives told us communication and individualised support had improved significantly, while 1 staff member said, "We've improved vastly since [Registered Manager] came here." Quality assurance systems monitored the impact of changes and supported ongoing development. This demonstrated the provider was committed to learning, innovation and improving people's quality of life.