Southview Lodge Residential Care Home

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 inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. We found 1 breach of legal regulations. Governance systems had not been effectively used to assess, monitor and improve standards or mitigate risk.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. One of the service’s publications encompassed the service’s vision by stating, ‘SVL is where people chose to stay, want to work and love to visit.’ The service’s business plan, management meeting minutes and governance meeting minutes detailed ongoing action plans, and we saw evidence of the action taken so far during our assessment. For example: improvements to the premises, staff recognition schemes and the introduction of ‘champions’ to support with various aspects of care delivery.

Not all leaders understood the context in which the service delivered safe care, treatment and support. Leaders did not always have the skills, knowledge and experience lead effectively. Whilst the registered manager had undertaken additional training and qualifications in health and social care, safeguarding and medication management to improve their skills and knowledge, risks were always not well managed. However, they did embody the culture and values of their workforce and organisation. Feedback from people and relatives about the registered manager was very positive. A relative said, “There have been big improvements since [registered manager] became manager. There have been positive changes and staff seem to be happier. The [registered manager] is up to date with their thinking.” Staff told us they felt well supported and the registered manager led by example.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff confirmed they had access to information about whistle-blowing and were confident concerns would be listened to. We saw evidence of staff meetings and surveys, and staff had the opportunity to raise concerns or share ideas in supervisions.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff expressed no concerns around discrimination or bullying within the service. Staff said they were treated fairly, and morale was good. A staff member told us, “[Southview Lodge Residential Care Home] is upbeat, I enjoy working with a good team.”

The service did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The registered manager and nominated individual explained quality assurance systems in place but acknowledged these were not always robust. For example, gaps to recruitment checks, MAR charts and health and safety checks (see ‘safe’ section of this report for more information). Processes for auditing the safety and quality of care were not always clear or effective at driving improvement. They had not identified or addressed concerns noted during our assessment. The service had not been clear about their regulatory responsibilities around incidents and accidents, and information of concern had not been shared with external partners as required. Following feedback, the provider confirmed they would review audits to ensure they were fit for purpose and sent an action plan to address other concerns. Though not yet fully embedded, some systems had recently been introduced or were in planning; to improve governance and oversight to care plans, medication management and staff competence.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. The registered manager explained how they shared details of their electronic recording system with other local care providers due to its effectiveness, and attended local care forums to share learning.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. The registered manager and nominated individual spoke about their involvement in service accreditation schemes, care conventions and new initiatives designed to support improvement. When asked If the service actively involved staff in understanding where improvements were needed and collective problem solving, a staff member said, “Yes, everyone can have their say.” Some staff had been given the opportunity to develop their skills in key areas and share learning with the team, to help improve the safety and quality of care.