Gordon Lodge Rest 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

We assessed all the quality statements within the key question of well led. We found significant shortfalls in the oversight of the service. There were no effective systems to monitor the quality of the service and to learn, innovate and improve. Staff told us they were confident to approach the manager and provider and were confident concerns would be listened to and acted on. The provider told us they worked to support staff’s mental health and wellbeing.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff described the culture at the service as supporting people to maintain their independence. They told us they respected people and treated them as they would like to be treated. One staff member told us, “It’s their home, if they don’t want to, they don’t have to, they should feel relaxed. I love them and want the best for them”.

The provider was not achieving the aims of the service detailed in their mission statement. This included, ‘creating a stimulating and positive atmosphere where residents feel safe and cared for, and are supported to continue to live active and fulfilled lives’. We found the atmosphere was not stimulating and people spent long periods of time without any interaction from staff. People were not supported to take part in pastimes they enjoyed and be active in the service or their local community.

Staff told us they felt supported by the provider and manager. They told us they were approachable and could be contacted at any time for support and guidance. Staff we spoke with had worked at the service for a number of years. One staff member told us this was because there was a positive relationship between staff, they respected each other and it was a friendly working environment . They commented, “I have stayed because I really like the work”.

The registered manager was also the provider. They were not on site frequently and were not leading the service.

Staff told us they were confident to speak with the provider and manager about any concerns they had. They told us these were listened to and acted on. A staff member commented, “They are approachable and I don’t feel afraid of them”. The provider and manager described to us how they chatted to staff each day and gave them the opportunity to share any concerns or suggestions. The provider told us they did not have an effective process in operation to regularly gather and analyse feedback from people, staff, relatives and professionals about the quality of the service.

Staff were asked for their views of the service during one to one meetings. However, there was no process in operation to collate this information and use it to drive improvements at the service. The provider has a clear whistleblowing policy in place which informed staff how they are protected as a whistle blower.

The provider told us they treated staff equally. For example, “I try to accommodate requests for leave at short notice for important events. If your staff are happy, the residents will be happy. I support staff to work the shifts they prefer and allow breaks and offer drinks”. The provider told us if they had any concerns these are discussed with staff. They told us they spoke with staff individually and then together to addressed the issues. They considered any disabilities staff may have such as dyslexia and agreed strategies to supported them fulfil their role. They told us staff were encouraged to share disabilities and work with the provider to look at the support that could be provided. They supported staff’s mental health for example, recognising difficult anniversaries and supporting staff to have time off to reflect. They told us they had improved staff’s attendance at work.

The provider did not have any processes in operation to ensure they were always working towards an inclusive and fair culture for staff.

The provider told us they did not complete audits of medicines. They had delegated this to 2 members of the management team and did not check to make sure audits were effective. The provider told us formal health and safety checks were completed by a contractor annually but they did not have any formal processes in place to keep the quality of the service under review. They told us they completed informal checks such as chatting to people and staff. The manager observed staff and worked alongside them. However, the processes were not completed regularly and were not recorded to check any shortfalls had been identified and addressed.

The provider did not have oversight of the service. They had delegated management tasks to staff and did not check to ensure they had been completed as required. Effective systems were not in operation to regularly review all areas of the service to ensure people received safe and effective care and treatment. For example, no checks had been completed on people’s care records, including care plans, risk assessments and daily notes to ensure they were accurate and complete. The monthly check of medicines processes did not look at all areas of medicines management and had not identified the shortfalls we found. This left people at risk of not receiving their medicines as prescribed to achieve the best outcomes. The last infection control audit was completed in August 2023. No further checks had been completed and some shortfalls continued. Again, shortfalls we found had not been identified and this left people at risk contracting an infection. Policies the provider had in place to support staff did not include important areas of practice. For example, the provider’s medicines policy was not sufficiently detailed to provide guidance to staff about their roles and all areas of medicines management. No guidance had been provided around when ‘required medicines’, checks and audits or recording the temperature all medicines were stored at.

People and relatives told us they were supported to receive care from professionals and their support was reviewed when their needs changed.

Staff told us they worked well with visiting health care professionals to meet people’s needs and keep them safe and well.

A visiting health care professional told us staff always shared the information required to support them to provide people treatment. They also said staff were available to support them if needed. The told us staff contacted their department at the right time and they followed instructions provided by the team.

The provider had not followed the processes they had in place to collaborate and work in partnership with others to share and learn from good practice. The provider's Autonomy and Independence policy dated January 2024 stated, ‘This Company is committed to the principles of co-production and will actively involve residents and other stakeholders in key decisions about how we develop and improve our services in the future’. However, they did not work in partnership to develop the service.

A member of the management team told us they were not aware of our new processes for assessing the quality of services. They told us they had previously attended meetings with registered managers but no longer took part in these to keep up to date with changes and innovations in care. We asked the provider to send us evidence of learning and improving at a service. They responded, ‘We have not got evidence of learning and improvement.’ The provider told us that through our assessment process they had recognised that they did not have formal processes in operation to record and review what happened at the service and this was an area for improvement.

There were no processes in operation to continuously learn, innovate or improve the service. The provider sent us an undated business plan. This was not specific and did not include timescales or costings for changes. Actions on the plan were not innovative and would not drive significant improvements to the service.