Ferrol 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 consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
 

This service scored 68 (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.

Staff described a positive and supportive culture and demonstrated an understanding of the service’s values in their day-to-day interactions. Relationships between staff and people were generally respectful, and there was evidence that people were treated with dignity and kindness. Systems were in place to support openness, including opportunities for staff to raise concerns, share feedback and contribute to service development.

Leaders promoted a culture of continuous improvement, using feedback from people, relatives and staff alongside governance information to inform changes. Engagement with external professionals and the wider community also supported an inclusive approach.

However, while the culture described was positive, there was variation in how consistently this was experienced in practice. In particular, inconsistencies in areas such as engagement and activity provision indicated that the service’s values were not always fully translated into people’s day-to-day experiences.

This reduced assurance that the stated culture was consistently embedded across all aspects of care delivery. While a strong, values-based approach was evident, the link between these values and consistently positive outcomes for people was not always clearly demonstrated.
 

The provider had leaders who were visible, approachable and demonstrated an understanding of the service, including people’s needs, risks and operational priorities. Leaders promoted values of openness, inclusion and person-centred care, and staff described feeling supported to raise concerns and contribute to improvements.

Governance systems, including audits, oversight processes and regular reviews, provided leaders with information about performance and risk. These systems enabled leaders to identify issues and respond to immediate concerns, particularly in higher-risk areas, and supported day-to-day service management.

However, although leaders were involved in the service and had access to information about how it was performing, they did not always use this information effectively to identify and address issues. Some audits were detailed and helped identify areas for improvement, while others were less thorough. This meant leaders could not always be assured that all areas of the service were being reviewed consistently. Actions identified through audits and other monitoring activities were not always clearly recorded, assigned or followed up, making it harder to demonstrate that improvements had been completed.

Leaders understood some of the areas where the service could improve, including how people were supported to stay engaged in meaningful activities and how outcomes for people were reviewed over time. However, there was limited evidence to show that this understanding consistently led to lasting improvements across the service. As a result, leaders could not always demonstrate how changes made had improved people's experiences or outcomes in the longer term.
 

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

There was evidence of an open and approachable culture, where staff, people and relatives felt confident raising concerns or sharing feedback. Staff demonstrated an understanding of their responsibility to report issues, including safeguarding concerns and incidents, and there were clear systems in place to support escalation and response.

People and relatives were encouraged to share their views through multiple feedback channels, including day-to-day conversations and resident meetings. Where concerns were raised, these were addressed promptly and appropriately, with feedback indicating that people felt listened to and informed of outcomes.

Staff described feeling supported by management and able to raise concerns without hesitation, reflecting a culture where speaking up was valued and acted upon. Learning from concerns and incidents was shared across the team, contributing to improvements in practice and reinforcing openness.
 

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.

There was evidence of a respectful and inclusive working environment, where staff felt valued and supported in their roles. Staff described positive relationships within the team and demonstrated mutual respect in their interactions, contributing to a cohesive and collaborative culture.

The provider supported staff through training, supervision and day-to-day management oversight, helping to ensure staff were equipped to meet the diverse needs of people using the service. Leaders promoted fairness and consistency in how staff were treated, with clear expectations around behaviours and practice that reflected the values of dignity, respect and inclusion.

Staff reported feeling able to approach managers with concerns or for support, which contributed to a culture where individuals were listened to and treated equitably. The stability of the workforce also supported continuity and consistency in care delivery and team relationships.
 

The provider did not always have clear responsibilities, roles, systems of accountability or effective governance processes. They did not consistently act on the best information about risk, performance and outcomes, or use this to drive improvement across the service.

Governance systems were not consistently effective in identifying, analysing and responding to issues. Audit processes varied in quality, with stronger, more analytical approaches seen in higher-risk areas such as falls and aspects of clinical care. However, in other areas, including environmental checks, recruitment systems and routine quality audits, processes were more compliance-focused and lacked sufficient depth to identify underlying concerns or provide consistent assurance of compliance.

Internal audits and oversight systems had not always identified issues found during our assessment, including concerns relating to recruitment records. This demonstrated that governance processes were not consistently effective in identifying and addressing areas requiring improvement.

There were also inconsistencies in how findings were translated into action. There was a lack of clear and consistent ownership, accountability and follow-through, which weakened accountability and reduced assurance that improvements were implemented and sustained. This limited the provider’s ability to demonstrate that identified issues, including those relating to recruitment and wider audit findings, were addressed in a timely and systematic way.

Although information from audits, incidents, feedback and external input was reviewed, there was limited evidence of structured analysis over time. As a result, patterns, trends and emerging risks were not always clearly identified or used to inform service-wide improvement.

While there were examples of learning leading to improvement, there was less evidence to show that learning was consistently embedded across all aspects of the service, including recruitment and workforce governance. This limited the provider’s ability to demonstrate sustained and consistent improvement.
 

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.

There was strong evidence of effective partnership working with external healthcare professionals, including GPs, community nursing teams, therapists and specialist services. Recommendations from these partners were consistently implemented, monitored and incorporated into care planning, supporting coordinated and responsive care.

The service demonstrated a joined-up approach to working across services, with information shared through care plans, governance systems and day-to-day communication. This helped ensure continuity of care and reduced the need for people to repeat their needs when engaging with different professionals.

Partnership working was supported through governance oversight, with external recommendations reviewed, tracked and followed through to completion. This ensured accountability and supported positive outcomes for people.

The provider also maintained links with the wider community, supporting residents to remain engaged with local groups, schools and activities, promoting wellbeing and social inclusion.

The provider did not consistently demonstrate a learning culture that drove improvement or innovation across the service. While some learning activity was evident, this was not reliably translated into sustained or measurable improvements for people.

There was evidence of learning processes in place, including the review of incidents, safeguarding events and outcomes through governance systems. “Lessons learned” reviews identified contributing factors and actions, which were shared with staff through meetings, supervision and handovers. The service also engaged with external professionals and used feedback to inform practice, indicating a willingness to learn.

However, this approach was not consistently effective or embedded. Learning was strongest in high-risk areas, such as falls, where analysis and targeted interventions led to improved outcomes. In contrast, across the wider service, learning activity was often reactive and focused on individual events, with limited evidence of broader analysis or service-wide application.

Audit systems and governance processes did not consistently demonstrate clear links between identified issues, actions taken and sustained improvements. In many areas, audits were variable in depth, with limited action tracking, ownership or follow-through. This reduced assurance that learning was embedded, monitored or maintained over time.

As a result, there was limited evidence to demonstrate how learning and improvement activity consistently led to measurable, person-centred outcomes. Opportunities to use learning to drive continuous improvement, innovation and improved quality of life for people were not fully realised.