Sutton 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, people’s safe care and treatment and good governance at the service. We have asked the provider to take action to improve 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. They did not always understand the challenges and the needs of people and their communities.

Staff could not explain to us the providers vision, strategy or values and how they were to apply them to their role. People, staff and relatives were not consistently involved in collaboratively developing the service. We found there were no effective systems in place to meaningfully involve people in providing input or co-producing strategies. Although the provider told us there was a suggestion box and that feedback was reviewed through a “You said, we did” approach, this only demonstrated that suggestions could be submitted and acknowledged. It did not show how people were actively involved in developing or shaping the solutions in response to their feedback.

Staff worked hard and tried their best to provide the best care they could. However, factors out of their control such as staffing numbers, meant high quality compassionate care could not always be achieved. Whilst staff had raised their concerns regarding insufficient staffing levels, systems were not used effectively to ensure staff were listened to.

This meant the provider was unable to measure service improvement as staff were unaware how their work contributed to overall improvement.

Leaders did not understand 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 or experience to lead effectively.

The management team were not competent at identifying risks and concerns.The provider had auditing systems and checks in place; however, these were not always completed accurately by the management team, resulting in an inaccurate view of the service. Audits completed by managers failed to identify the concerns we found during our visits; therefore, we were not assured the management team had the skills and knowledge to effectively do their role. Where external partners had completed audits and identified risks, such as people not receiving their medicines on time, staffing concerns and inadequate risk management care plans in place, the managers failed to address these concerns.

The failure to identify risks and concerns meant people were not always protected from the risk of harm. Staff told us they lacked confidence in the home’s leadership and were worried about the health and welfare of people as a result. This meant ineffective management, governance and oversight.

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

Staff told us they felt able to raise concerns but reported that their feedback was consistently not acted upon or valued. One staff member said, “We have the freedom to speak, but we are not believed and no action is taken. Staff say, ‘what’s the point raising it, nothing will be done.’” Most staff were unable to explain the whistleblowing policy or who to contact externally if concerns were not addressed.

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.

While staff had completed equality, diversity, and inclusion training, they did not feel valued or treated fairly. For example, one staff member reported being refused a 12-hour shift for their wellbeing, while others worked 15-hour shifts. Staff on 8-hour shifts sometimes worked six days in a row. There was a lack of an open and fair culture, which resulted in staff feeling they were not treated equally. This meant the provider had not always ensured all staff were equally supported or that inclusive practices were consistently applied.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

After our assessment the provider told us the registered manager was no longer in post. There had not been a consistent registered manager at Sutton Lodge; three different managers had been in post over the past three years. Staff told us this had a negative impact on the service. The management structure and oversight systems, including audits, were ineffective in identifying concerns and risks to ensure safe care. Despite multiple managers and completed audits, issues such as staffing levels, lunchtime experiences, unsafe medicine management, ineffective risk management, inaccurate care planning, and poor staff morale were not identified. There was no system to analyse information or identify trends, including accidents, incidents, and near misses, to drive improvement. Management daily walk arounds were not effective because they had not identified the high risk concerns we had found during our assessment. The provider was also not always open or transparent in communications with commissioners or the CQC, they had not reported all required incidents to the CQC or the local safeguarding team.This meant there was an ineffective oversight and systems in place to support staff and identify risk meant governance processes were not robust enough to ensure safe care.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

We found shortfalls in the oversight of incidents and accidents. Not all reportable incidents had been submitted to the CQC, or the local authority safeguarding team as required, placing people at risk of harm or abuse due to poor reporting. There was not an effective system in place to involve health professionals when people declined their medicines or when there were delays in administration. Support from healthcare professionals was not always sought. This meant people were at risk of harm.

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.

The feedback we received from staff, demonstrated the management team did not always have a positive, compassionate, listening culture to promote trust and understanding with each other to allow learning and improvements. There was no effective quality assurance system or process in place to obtain feedback from people living at the service, relatives, staff and professionals. This meant there were missed opportunities to obtain people’s feedback and take appropriate action. Where concerns had been raised, action was not always taken to improve safety and quality. For example, following a local authority visit, areas requiring improvement had been identified, however the provider had not implemented sufficient changes, and we continued to find similar concerns. For example, staff deployment, medicine management, car planning and ineffective review of falls. This meant people were at continued risk of harm as appropriate action had not been taken.