Imperial 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

The provider had made improvements since the last inspection. They had addressed areas of concern and had effective systems for monitoring and improving quality. The exception to this, was in relation to monitoring cleanliness. Staff had recorded they had cleaned and checked areas when this was not always the case. The provider's systems had not identified this. We discussed this with senior staff who acknowledged this and started to develop more robust systems for checking. There was a positive culture at the service. Staff felt supported. Staff and people using the service had good links with external professionals. Staff followed best practice guidance to help ensure people received good quality care. The registered manager was appropriately experienced and qualified. People and staff felt the service was well-led.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff explained there was a positive culture and they worked well as a team. They felt people using the service and staff had opportunities to speak up and they were listened to and respected. Records confirmed this.

There had been improvements at the service, including better staffing levels and staff training and support. This enabled the staff to work alongside the provider to meet their values and objectives.

Staff told us the registered manager was supportive. They said they supported them to learn and understand best practice.

The registered manager was also 1 of the partners who owned the service. They were experienced and had a good knowledge of how to support people with mental health needs. They kept their training and qualifications up to date with best practice.

Staff told us they knew what to do if they had concerns. They felt confident that they would be respected and listened to.

There were procedures to ensure people and staff could speak up. There were regular meetings for people using the service and staff. They were encouraged to share their views. The provider's complaints procedure was displayed and there was information about advocacy groups and others who people could speak with.

Staff told us there was equality and respect. They felt supported to express their views. Their personal needs were met because the provider allowed staff time off or support when needed.

There were procedures to help protect staff and ensure their rights were being met. These included contracts of employment and opportunities for them to learn, speak up and have supervision.

The staff understood the importance of following procedures and good record keeping. The deputy manager was in the process of reviewing and improving records. They were able to show us improvements they had made and discussed plans for further improvements.

The provider had a range of policies and procedures. These reflected good practice guidance and legislation.

People told us they were supported to access external resources, including healthcare teams.

Staff explained how they worked with external professionals, making referrals, seeking guidance and sharing information.

We did not receive any direct feedback from external partners. The provider's records showed there were good systems for communication, and they worked well with partners.

People's care plans were regularly reviewed with multidisciplinary teams. There was evidence of partnership working to plan for and monitor risks.

Staff told us they were involved in carrying out checks and audits. However, they were not aware that some of these checks had not been carried out to the required standard. We discussed this with the deputy manager and they acknowledged where improvements were needed.

The provider had a range of checks and audits. These had not always been effective in identifying when improvements were needed. For example, around cleanliness. There was a schedule to tell staff when audits needed to take place. There was clear information, and these had been followed. There had been improvements at the service since the last inspection. There was evidence the provider had identified other concerns and action plans to show how these were being addressed.