Steven 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

A robust and effective quality assurance and governance system had not been implemented since the last inspection when this was identified as an area of concern. The registered manager acknowledged this shortfall and planned to improve it. We have found a breach of regulation in relation to 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.

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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

At our last inspection we identified policies had not been kept up to date with new developments in social care, we recommended that the registered manager update all their policies to required standards. Further work was needed in this area, we identified guidance had not been followed in respect of managing environmental risks. We found 1 breach or regulation relating to governance. Governance systems and audits were not effective in identifying or addressing areas for improvement. At the last inspection we identified an effective system had not been embedded to assess, monitor and improve the quality and safety of the service provided and audits had not been carried out on support plans, incidents and accidents, medicine, and staff files. Although we found some improvement and some audits were now being carried out further work was needed to ensure a robust system of auditing and oversight was embedded. The registered manager now completed audits on some areas such as dignity, medicine, and spot checks on staff competence and performance. However, more work was needed to ensure complete oversight of the service although we found minimal impact on people.

Staff were positive about the management and governance of the service. They told us, “We get a lot of support, and the manager is approachable. I've worked in some places and you are frightened when the manager comes. But here, they are so welcoming and helpful. If you make mistakes, you learn but you don’t feel scared to make mistakes. I get supervisions often. I like the management style, manager is hands on. My ideas are taken on board, we have meetings every Wednesday.” However, we identified continued shortfalls in the governance and oversite of the service. The registered manager told us quality assurance and governance was in the process of being improved. They said, “Auditing, the system we had was not robust enough, we are doing a new one now to reflect what we are doing. We haven’t really got it straight yet.”

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.