The 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.

The service was in breach of legal regulation in relation to governance of the service.

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. They did not always understand the challenges and the needs of people.

There was evidence of a generally positive day‑to‑day culture, with staff interactions observed to be kind, caring and respectful, which supported people’s wellbeing. Staff and leaders expressed a commitment to providing good-quality care and to helping people live fulfilling lives, and leaders worked with people, relatives and staff to promote meaningful experiences.

However, we also identified a culture in which restrictive practices were used at a high level when people became distressed, suggesting restraint was too often the default response.

This indicated that staff and leaders did not always fully understand or respond to the challenges faced by people, nor tailor their approaches to meet the diverse needs of individuals and their communities. As a result, the service did not consistently balance positive relationships with rights‑based, least‑restrictive approaches to care.

Leaders did not always demonstrate the skills and knowledge required to lead the service effectively.

The provider had failed to identify and effectively address the concerns we found during the assessment. For example, the use of restraint, incident analysis, staff training, and care records. This meant there was an increased risk to people living at the service. The registered manager required additional support from the provider to address these concerns and the provider committed to putting additional support measures in place following our feedback.

Despite these concerns, we received positive feedback from staff and relatives.

People did not always feel they could speak up and that their voice would be heard.

The provider had policies for raising concerns, freedom to speak up and whistleblowing. However, these did not reflect best practice guidance. The providers policy advises who the freedom to speak up guardian is; however, this is does not signpost staff to an individual independent of the leadership structure. Although staff told us they felt able to raise concerns, they were unsure who the freedom to speak up guardian was. The provider did have an external option, but this was not referenced in the appropriate policy and procedure. Reducing clarity about the formal process and where to seek independent support if needed.

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.

Systems were in place to identify and review staff needs, including regular supervision and team meetings, where individual circumstances and required adjustments could be discussed.

Staff told us they received support when adjustments were required. One staff member told us: “Definitely, they support with adjustments. I am on a flexible contract, and I was listened to well for this.”

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 were not robust or effective in supporting day to day quality assurance or driving improvement, and audit activity was not used meaningfully to monitor performance or service quality. Auditing and assurance processes were poorly managed and did not identify or address risks or shortfalls in practice. Established systems were not consistently implemented in line with policy, and provider oversight was insufficient to ensure required actions were completed.

Information governance arrangements were inadequate, and people’s personal data was not always stored securely. However, the provider has since improved this.

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.

We saw evidence of partnership working with health professionals for example people’s medication was reviewed annually with a relevant health professional.

People were supported to access the community as they wished, and one person was supported to attend a day centre.

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.

The lack of oversight of systems and processes meant that concerns were not consistently identified or addressed, limiting opportunities for learning and improvement. As a result, there was little evidence of lessons being shared with staff to support improved practice.