Ormsby 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 good governance.

This service scored 50 (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 always have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider's Statement of Purpose outlined a clear set of values, including a commitment to delivering person-centred care, promoting independence, and enabling choice and dignity.

These values are consistent with national good practice frameworks such as Valuing People, and the documentation reflects an intention to support individuals in a respectful and inclusive environment.

However, while the provider's vision was clearly articulated, it was not consistently embedded in day-to-day practice. During our inspection, we found that the principles outlined in the organisation’s philosophy were not always reflected in the quality or safety of care delivered.

Risk assessments for people were often outdated or generic, staff had not received essential training, and people were not always meaningfully involved in decisions about their care and support. Incidents were not routinely analysed to promote learning, and care plans did not always reflect current or individualised needs.

Leaders demonstrated awareness of some of the challenges, but there was limited evidence of a clear, proactive strategy to ensure consistent implementation of the organisation’s values across the service. This reflected shortfalls between the provider’s stated aims and the lived experience of people using the service.

Not all leaders understood the context in which the provider 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.

Leaders were open and transparent about areas for improvement, and some leaders told us that they did not feel they had the relevant training to support them to fulfil their role. Leaders did not have robust oversight of quality and safety of the service.

During our inspection, the Nominated Individual began to take proactive steps to address these issues. They had sourced an external consultancy agency to support improvements in leadership, practice, and quality monitoring.

Despite these concerns, we did see examples of compassionate leadership when managers were directly involved in care delivery. Leaders demonstrated familiarity with the people they supported and, in some cases, stepped into care roles when staffing levels required.

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

The provider had a whistleblowing policy in place, and most staff told us they felt confident to raise concerns if needed. Most staff described the management team as approachable and supportive, with one staff member stating “Yes 100% would speak up if needed. She always says if there’s any issues, please make sure that you come to me or to someone who can help.” This reflects a generally positive and open culture among the staff team.

A person living at the service told us “They [senior and manager] are friendly and always happy to listen.”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they felt safe and supported by their colleagues, particularly during incidents involving distressed behaviours. There was a clear sense of teamwork, and many staff said they could rely on each other in challenging situations.

One staff member told us they did not feel valued. They described feeling unsupported and believed management had not taken appropriate steps to ensure their wellbeing. This was not echoed more widely among the staff we spoke with, but it highlights the need for the provider to ensure a consistent and equitable approach to staff support.

There were no reliable systems in place to ensure one-to-one supervision sessions or regular team meetings took place. Staff said this limited their opportunity to share concerns, receive feedback, or reflect on practice.

The provider had not established effective mechanisms to ensure all staff received consistent support or had regular opportunities to discuss their development and wellbeing.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. This inspection found significant and widespread failings in the governance systems and oversight at the service.

The provider failed to ensure effective systems were in place to assess, monitor and improve the quality and safety of the service.There was not consistently effective oversight of key safety areas including fire safety, infection prevention and control, staff training, recruitment, and medicines management.

For example, fire safety systems were not robust. Checks were out of date, fire drills had not been scheduled since February 2024, and Personal Emergency Evacuation Plans (PEEPs) were outdated, referencing staff who no longer worked at the service. Environmental risk assessments were outdated, with some last reviewed in 2008. This compromised fire safety and put people at increased risk.

There were shortfalls in the systems to support safe recruitment and staffing. Staff files lacked important documents such as references, interview notes and right-to-work checks. One staff member had expired documentation, which had not been identified until the inspection. This had not been identified by audits, and no action was planned to address shortfalls.

Workforce training and development had not been prioritised. Staff training records showed significant gaps in mandatory training including in conditions impacting people. There was no reliable oversight of training compliance, and leaders told us that they did not feel they had received the relevant training to fulfil their roles. Gaps had not been identified by audits or feedback from staff and with no improvement plan.

Systems to respond and learn from incidents were not effective in driving improvement or reducing the risk of reoccurrence. Most reported incidents involved behaviour that challenged, but there was no structured review, analysis or follow-up. Risk assessments and support plans were not routinely updated in response. This meant the service missed opportunities to learn from events and reduce future risk.

The provider failed to ensure their policies always reflected up to date national guidance and best practice. This included policies around safeguarding and recruitment. This meant that staff did not always have the correct guidance in place to promote effective working practices.

Although the nominated individual had begun engaging with an external consultancy to support improvement, this had not yet led to tangible or sustained changes. Leadership did not demonstrate a clear or effective plan to address the widespread failings identified at this inspection.

The absence of effective oversight, planning, and action significantly increased the risk of unsafe or inappropriate care.

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.

Professionals told us the service was proactive in seeking advice and responsive to feedback. One professional said, “They actively seek input from external professionals and are receptive to suggestions aimed at improving the quality of care.” Another told us, “They share information with me straight away and are always transparent.”

The provider worked with professionals to make timely referrals, sought advice when needed, and took action to improve people’s lives. A professional shared, “They made a huge difference to one gentleman’s quality of life by helping him access the community again.”

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system.

Shortcomings in staff training, risk assessment, incident review, and workforce management demonstrate systemic weaknesses that have gone unaddressed, limiting opportunities for meaningful improvement. The lack of effective monitoring and evaluation has prevented the organisation from identifying patterns, learning from incidents, and driving continuous development.

The nominated individual managing this service also oversees another service within Ormsby Group Limited, which was inspected earlier in 2024 and rated Requires Improvement overall. During that inspection, similar concerns were identified relating to safeguarding systems and processes, staff training compliance, supervision and appraisal practices, recruitment procedures, and the effectiveness of governance and quality assurance systems. This learning had not been utilised to drive improvement across the provider’s services, demonstrating gaps in the providers systems for learning, improvement, and innovation.

The manager demonstrated awareness of some of the issues affecting the service; however, the volume and complexity of concerns limited their ability to prioritise and address them effectively. This situation reflects the need for clearer focus and capacity to support meaningful learning and sustained improvement across the organisation.