Haven 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 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 regulation 17 good governance at the service.

This service scored 43 (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. A recent internal investigation into concerns raised concluded the service had indications of a closed culture. Team dynamics were described by staff, with reports of cliques, exclusion, and a lack of collaboration. Some staff shared they felt isolated and segregated, particularly when raising concerns. Since the investigation a new management team had been put in place to monitor staff culture. Staff representatives had been invited to attend regular meetings with the area manager alongside representatives from other services to discuss concerns and build trust. Staff had completed equality training and training to revisit the organisations values and codes of conduct.

The provider did not have consistent leaders who understood the context in which the service 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. Following concerns shared with the organisation an internal investigation was completed, and issues were identified at the service. Investigations identified that audits and quality assurance checks had not always been completed honestly, and tasks had falsely been recorded as completed. Since the investigation an acting manager had been put in post and was receiving regular support from the provider’s leadership team. Action plans had been put in place and more robust governance systems had been implemented.

People did not always feel they could speak up and that their voice would be heard. A number of issues had been identified at the service; this had been highlighted following the speaking up of a staff member that led to an internal investigation. The internal investigation raised concerns regarding the culture in the service. During the investigation staff reported the reason they did not speak up was due to a fear they would not be listened to, no actions would be taken, and this would cause issues for them in the workplace.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff had raised concerns with workload, uneven task distribution, feeling overwhelmed, and a lack of recognition for covering shifts and other roles when required. Staff expressed frustration at being expected to meet high demands without adequate support or appreciation. Some improvements were noted by staff following recent changes of management.

The provider did not 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. We looked at a number of audits for 2025 including medicines, infection control and care plans audits. Not all audits identified ongoing issues or actions. However, this was being addressed by the interim management team. More robust systems had been implemented.

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. Accidents or incidents had not always been recorded. This had not allowed for analysis of all incidents, learning, referrals and sharing of information with partner agencies when identified as appropriate prior to late June 2025. This had been addressed and referrals to appropriate partner agencies were being made to allow for effective collaboration.

The provider did not 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. We found no records of any meetings with people’s relatives. The provider had recently commissioned an independent survey to gain the views of staff and relatives. However, the feedback received was limited and due to the identified issues with possible closed cultures, staff feedback at the time of the survey was not consistent with feedback following the internal investigation into the service and feedback shared with us. Following the internal investigation the provider had completed action plans for improvement, staff had received training and had revisited the values and codes of conduct of the organisation with the staff team. The provider is currently seeking to recruit a new permanent manager for the service.