Archived: Ruth 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 inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulations in relation to the lack of robust governance at the service the failure to display their CQC rating.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

As at the previous inspection, leaders did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. We identified a closed culture at Ruth Lodge. (A closed culture is a poor culture in a health or care service that increases the risk of harm.) Leaders including senior care staff were not consistently demonstrating or role modelling a positive culture at the service. At this inspection, there had been no improvements.

Leaders did not role model a shared vision, strategy or positive culture to staff. This had a major detrimental impact across all areas of people's lives. Despite the provider telling us activities had increased, and people were leading more meaningful lives, we found this was not the case. Staff and leaders did not demonstrate the required skills or capability to deliver person centred care or to ensure risks were well managed. They failed to recognise they had developed a closed culture that did not promote or uphold people’s rights.

We found Leaders were using undignified language in 1 person’s care plan repeatedly references that they ‘suffered’ with autism and ‘suffered’ with a learning disability. The provider made continued references to a person’s fear of injections due them having a ‘learning disability’. They had not considered this fear could have been as a result of a previous trauma in the person’s life.

The leadership team had not identified the institutionalised practices in the service. This included 1 person routinely being taken to bed before night staff came on duty and given 2 baths a day without evidence they wanted or required this. According to a team meeting staff were asked to decide a new menu for a person rather than involve the person in this. There was culture of providing care to people rather than involving them or encouraging them to learn new life skills. One relative told us, “They (staff) do everything for (person). He’s not been stimulated to do anything; they just do it for him.”

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

After the last assessment in December 2024, we saw from minutes of a staff meeting ‘staff rendered their apology and their willingness to improve.’ Providing staff with the necessary resources, training, and support is crucial for enabling them to deliver high-quality, person-centred care. The provider failed to do this and instead accepted their apology to ‘do better.’

Leaders told us that staff were now able to take formal breaks during their 12-hour shifts. They told us the manager, or another member of staff would support the person whilst staff took their breaks. The manager said, “They can stay in the staff room or go out.” However, we saw from a staff meeting in September 2025 that staff were told they could not leave the property during their breaks.

In addition, we found there was a lack of transparency from leaders. For example, 1 member of staff’s typed supervision record related to another of the provider’s service that the member of staff had never worked at. The record referenced things the member of staff said about the service, the person living there and staff they had worked with there. However, this conversation could not have taken place given they had not worked there. Leaders confirmed this conversation did not taken place. We saw the handwritten handover records from night staff did not always reflect who was actually on duty at night. It was not clear why a member of staff would record the care for a person when they were not at work.

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

Leaders and staff did not value people or seek their views or feedback. There was a closed culture where the voices of staff and people were not seen as essential, valuable or important. Staff told us they were able to speak up confidentially with one telling us, “If there is an issue I can speak up. We also have the suggestion boxes to discreetly raise concerns,” However we found in practice this was not always happening. As stated, it was seen from a staff meeting that they apologised for the failings at the service. There were inadequate processes in place to ensure people and staff felt empowered to speak up. We saw from staff meetings; staff were not asked to contribute to any concerns they may have. Instead, the minutes just discussed matters of policy, procedure and training.

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

There were concerns with the staff working hours and restrictions on how they took their breaks. We also identified concerns that not all staff had opportunities to have one to one discussions with their manager. Staff that worked alone at night were not given appropriate support. The provider told us the managers would keep contact with night staff via a WhatsApp chat. However, staff we spoke with told us they would only hear from managers at night if there was a specific need. They said they do not routinely hear from managers whilst on night shift

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.

Governance and management of the service continued to be inadequate. There was a continued failure by leaders to take accountability of their performance, and the performance of the staff they managed, and how this impacted the quality of people’s lives, and their safety. On discussions with leaders, they lacked any understanding of the principles of national guidance and legislation including MCA and of Right Care, Right Support and Right Culture.

Leaders failed to identify through audits the institutionalised practices. The audits that took place mainly focused on the health and safety of the environment but failed to focus safety of care to people and the person-centred approach to care. There were no audits undertaken during the night shifts to establish if there were any concerns or any areas that required improved. Leaders were unable to provide evidence of an effective system to assess, monitor and improve the quality and safety of the service, and people continued to experience poor outcomes because of these failures. The provider also failed to ensure they were displaying the rating at the service from their last CQC inspection which is a legal requirement.

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

The manager provided us guidance from a Speech and Language Therapist (SaLT) from 2015 for one person that included information on how the person could further develop the person’s independence skills and ‘improve their quality of life’. This included a communication passport, visual timetables and intensive interaction none of which was being utilised by staff to support the person. There was also no evidence leaders had asked for further support from the SaLT to determine whether there had been any updates to this guidance. A member of staff told us, “You need professionals. What you may think they may think differently. It’s better to have a professional so that they will come and guide us how to go about things.”

Leaders did not work collaboratively with partners and stakeholders. Because of this, people did not receive the right care when they needed it and were at risk of receiving unnecessary treatment and restrictions. People did not experience seamless, joined up care, instead, their care was disjointed, and inaccurate and avoidable risks were ongoing because of these failures. One external professional fed back, “We cannot see what support they (the leaders) feel the residents need and how staff should deliver that support.” They told us there was a lack of actions taken by the provider to seek appropriate support from external health advisors in relation positive behaviour support.

The failure to collaborate, lack of transparency, and unsafe misinterpretation of clinical professional guidance not only meant that people were failed by leaders and staff they put their trust in to keep them safe, but they were at ongoing risk of harm.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

As at the previous assessment staff and leaders lacked understanding, skills and capability to make and sustain improvements. There were missed opportunities to reflect and make improvements on care. Leaders told us they had reflective sessions with staff and although there were documents in place referencing reflective practice, these lacked substance and detail. They often just repeated the incident that occurred and that staff were to continue to monitor. There was no evidence of any surveys with relatives or external providers which meant they missed opportunities to gain feedback, learn from this and make improvements. There was also evidence that relatives were not always contacted when their loved one had been the subject of alleged abuse.