Clipstone Hall & 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

Staff told us they had clear roles and responsibilities but at busy times they lacked direction from management over their priorities. The registered manager was new to the service but feedback about the registered manager was positive, and staff felt they were able to raise their concerns freely and openly. The registered manager and provider had clear oversight of the service through audits and quality assurance checks which promoted good person-centred care. The registered manager had ensured statutory notifications were consistently submitted to stakeholders as required. There were quality assurances processes in place and any feedback given was acted upon. Leaders implemented relevant or mandatory quality frameworks, recognised standards, best practices or equivalents to improve equity in experience and outcomes for people using services and tackle known inequalities.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff we spoke with were positive about the registered manager. They stated the registered manager was open, approachable and supportive however they were still forming a relationship as the registered manager was new to the service. One staff member said, "[The Registered Manager] seems proactive so far,” another said, “We have been let down before through so many changes in manager, it’s hard to build trust.” During the inspection we observed several staff members using the open-door policy and approaching the registered manager for guidance and support. The registered manager stated they were building relationships with staff and was fostering open and clear communication to ensure staff felt valued and supported.

The registered manager was knowledgeable about succession planning and upskilling of staff and planned to implement a succession plan in the future for all staff. Deputy managers were supported to step up in the manager’s absence to ensure care standards remained consistent and staff always felt supported. The provider had a comprehensive support and induction programme for the registered manager which provided clear responsibilities and accountabilities.

There were relevant policies and procedures in place to support staff and management to speak up. The registered manager had an ongoing action plan for the home which evidenced where staff had highlighted issues or concerns. The action plan had recorded these and followed them through to completion. These were reviewed by the provider monthly to ensure staff and the registered manager received the support required in a timely manner. The provider was knowledgeable about closed cultures and was looking to implement further learning to support staff in identifying potential closed cultures.

Staff we spoke with were knowledgeable about how and where to raise any concerns. Staff told us they were confident to do this and knew how to escalate their concerns if they felt not action had been taken. One staff member said, “Previously I raised an issue with the provider as the manager was absent and they were responsive.”

Staff told us they were supported by the registered manager and provider equally and fairly. One staff member said, “They [registered manager] have been really good, I have been offered flexible working to help with a health condition.” Staff were knowledgeable about protected characteristics and had completed relevant training.

The provider had relevant policy and procedures in place to support workforce equality, diversity and inclusion. The provider was also in the process of rolling out a positive culture toolkit to further support this policy. This included support to recognise discrimination and ways of working that were inclusive for people, relatives and staff.

The provider had relevant policies and procedures in place to assist with the governance of the service, this included an up-to-date business continuity plan. The registered manager completed a range of daily, weekly and monthly compliance audits to ensure the quality of the service, including infection prevention control, medicines, training and care planning. However, we raised some concerns with the registered manager in relation to staff deployment and resourcing in the home and they agreed to review this area for development. Where other gaps or shortfalls were identified these were addressed by an action plan with completion timeframes which ensured a timely resolution. The provider reviewed audit processes and any learning from this which was shared with the team and the wider business. The service had established means of sharing information with staff including team meetings, email and sending messages through the electronic devices they used as part of their role.

Staff told us they were clear about their responsibilities however felt they lacked direction over their daily priorities. One staff member said, “Sometimes I can’t complete everything that needs doing, I ask management what the priority should be, but no one gives me an answer, I just do my best.” Another staff member said, “I have no idea what my priorities are. I have a whole list of stuff to do but no guidance as to what order it needs to be done it and if things go mad (emergency) I don't know what’s best to leave to the next shift.” Staff raised concerns about workforce planning and deployment within the home. Please see evidence provided under the effective staffing quality statement. Staff confirmed they had secure digital access to care plans and received updates through electronic messages as well as daily and team meetings.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.