Rose 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 management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We found the provider was in breach of the legal regulation relating to good governance.

This service scored 57 (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.

The majority of staff were not familiar with the provider’s vision and values. Reports showed not all staff had read the provider’s policies and these were not routinely discussed during bi-monthly staff meetings. Staff told us they received the training they needed to carry out their roles. However, some suggested having more ‘hands on’ training rather than e-learning. Feedback from staff regarding the workplace culture was mixed. Some staff reported feeling well-treated and found management approachable, whilst others highlighted inconsistencies in how staff were treated and described the environment as unsupportive. A staff member told us, “The culture of ready to help is in the air.” Another staff member said, “I don’t feel valued by the provider.”

Not all leaders understood the context in which the provider delivered care, treatment and support. Management had not always embodied the culture and values of their workforce and organisation.

While leaders possessed the necessary skills, knowledge and experience to lead effectively, this was not consistently reflected in practice. Staff feedback was mixed, some praised the standards of the management team, while others identified areas requiring improvement. Recurring themes among staff was the need for better communication and increased staffing levels. This was also reflected in the results from the provider’s, colleague engagement survey. One staff member told us, “Morale can become flat and we don’t feel valued. At other times, we are full of life and loving our workdays.” In contrast, feedback from people and their relatives was generally positive. One relative commented, “I go to [Registered Manager] if I have any issues and they sort it out.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider and registered manager positively encouraged feedback about the service.

People and their relatives were encouraged to share their views about the service through annual quality surveys and were invited to attend regular meetings where information about the service was shared with them, and they could express their views about the care and support received. One person told us, “I go to the meetings, they tell us what’s going on.” A relative said, “Every month there’s a family meeting.”

Systems were in place to make it easy for people to raise complaints about their care and support. People and their relatives felt confident to raise concerns. Processes were in place for staff to ‘speak up’ about the service. The provider had a clear whistleblowing policy and procedure in place. Most staff described how their views were welcomed and encouraged in regular team meetings, annual surveys and supervision sessions.

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

The provider had systems in place to consistently look at how to improve equality and diversity for their workforce. Best practice guidance was followed by the management team to recruit staff fairly. 91.8% of staff had completed equality and diversity training and most staff had read the provider’s Equality, Diversity and Inclusion Policy.

The provider did not have clearly defined responsibilities, roles or systems of accountability to support effective governance. There was a lack of robust oversight, which contributed to the breaches of regulations. Although quality audits and checks were in place, they did not identify or address issues such as infection control, medicines management and record keeping, which we found during this assessment. Additionally, legally required notifications had not been submitted to the Care Quality Commission despite the requirement being detailed in the provider’s safeguarding policy. We raised this with the provider and the registered manager for them to address.

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 registered manager and staff had good knowledge of the local services and how to access them. They collaborated and worked in partnership with health, social care and community partners to improve people's health, care and wellbeing. Staff made appropriate healthcare referrals and appointments for people, when required.

External professionals told us the service had developed good links with them. They found the registered manager and staff responsive to suggestions made about providing individualised care and support. A healthcare professional told us, “The service acts on any instructions and advice you give them.” People and relatives told us staff worked well with other professionals so they could access appropriate care and treatment, when needed. One person told us, “I had my feet done the other week” and a relative said, “[Name] see’s their own NHS chiropodist. They are registered with the local GP practice and the nurse practitioner visits when required.”

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 was committed to continuous learning and improvement through regular audits and quality assurance checks. However, these were not always effective at identifying and addressing issues as observed during our assessment.

There were systems to ensure lessons were learned when things went wrong. Accidents, incidents and safeguarding concerns were reviewed and analysed to identify any emerging themes or patterns. Where necessary, changes were made to practice reducing the risk of recurrence and improving outcomes for people using the service.

Information and learning from accidents, incidents and complaints were shared with staff through regular team meetings and daily handovers. This helped ensure staff remained informed and supported a consistent and proactive approach to safety and risk management. A healthcare professional told us, “There were issues with the staffs moving and handling. I raised it and it was addressed with more training for staff and refreshers for safe moving and handling.”