West Lodge 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

We identified a breach of the legal regulations. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. Though the assessment of these areas indicated areas of concern since the last inspection, our rating for the key question remains requires improvement. There were not clear and effective governance, management, and accountability arrangements. Staff did not always understand their role and responsibilities. Managers did not always account for their actions, behaviours, and performance of staff. The systems to manage current and future performance and risks to the quality of the service did not take a proportionate approach to managing risk to allow new and innovative ideas to be tested within the service. Data or notifications were not consistently submitted to external organisations as required. Information was not used effectively to monitor and improve the quality of care. We have taken action and asked the provider to make improvement.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were unable to explain what the providers shared direction and culture was. This meant there was no effective shared strategy in place to share the providers vision so that all staff in all areas know, understand and support the vision, values and goals.

The provider did not have a system or process where people, staff and relatives could be involved in developing the vision, values and strategy through a structured planning process in collaboration. The management team did not demonstrate a positive, compassionate listening culture. The registered manager told us after day 1 of our visit they would be using reflective practice, supervisions and staff meetings to help improve staff understanding and practices. However, we found on day 2 of our visit these were not successful: they did not bring about the significant changes in staff practice needed to ensure people were at protected from harm and received safe, high quality and compassionate care.

Staff told us the management team were capable, compassionate and inclusive leaders. One staff member told us, “I am very supported in my role, the training we get, the equipment we have and we get a lot of encouragement from management and good communication. But also, even support with our wellbeing and health. They always listen and take action."

People continued to receive a service that was not well-led. The provider did not understand their role, or regulatory requirements, and lacked effective oversight of the service. Issues we found at the last inspection continued to be found at this inspection. This meant people continued to be at risk of receiving unsafe care and treatment.

Staff knew how to raise concerns and were confident action would be taken. Staff told us they felt they had the freedom to speak up. A member of staff told us, “Yes I do. We have a good relationship with the management, we have the freedom to raise any concerns. The work environment is very friendly we are not worried about raising any concerns with them.”

The provider had systems and processes in place to enable staff, people living at West Lodge Care home and their relatives to speak up. There was a whistle blowing policy in place which provided guidance to staff about how to raise concerns. There was also a complaints policy. Staff meetings and handover meetings were held including for staff to provide them the opportunity to speak up.

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.

There was no governance process, system or culture in place to reduce the number of incidents and ABC (antecedent, behaviour, consequence) incidents. The registered manager did not have an oversight of the incidents and ABC incidents. There was no audit completed by the management team. The management team told us, the outreach nurse read all ABC records when they visited. However, the provider failed to have a clear system and process in place for subsequent learning on how to prevent incidents in the future. This placed people at risk of incidents reoccurring because lessons learned from incidents were not robustly reviewed, recorded and shared. Staff told us they felt there were robust systems and processes in place. During the assessment the provider and registered manager did acknowledge improvements needed to be made to their governance systems to ensure they had an accurate overview of the service.

The provider did not have effective systems and processes in place to assess and monitor the care being provided. There was ineffective quality and safety monitoring in place. Systems to audit the quality and safety of the service were not always effective in identifying and addressing areas for improvement. There was not a competent staff team in place to ensure good governance of the service. For example, medicines audits and systems had not identified the issues we found during our assessment. Medicines audits had been conducted. However, staff failed to identify concerns, risks and effective action had not been taken to address the issues found. The audit failed to identify checking for two signatures on handwritten entered medications on the medication administration record, stock recording of tramadol medicine, medicines that need to be administered before food or drink and ensuring good management of insulin storage. There had been a lack of effective clinical governance across the home, and this resulted in systematic issues with management of risk and health conditions and placed people at risk of harm. We found serious shortfalls in the management of pressure area care and wound management which placed people at increased risk of harm. The management did not have a system to ensure ongoing wound management records were completed. This meant staff were not provided with information and guidance on how to manage the wound.

The management team told us that they did not always have a good working relationship with a health professional, but they told us this did not impact on the care and support people received. However, we had received information from partners that demonstrated this did have some impact on peoples health care support.

Staff told us they had good partnerships working with the local authority and NHS teams that visited.

We received mixed feedback from professionals involved in the home. Some felt communications needed to improve to provide better outcomes for people. Others said communications were good and the service worked well with them. All professionals we spoke with felt the home was chaotic at times and people's needs were not assessed to ensure staff could meet their needs and if West Lodge Care home was the appropriate placement for some people. One professional we spoke with told us people had raised they wanted to access the community for social engagements and the provider was working with them to so this.

The provider did have a process to ensure when partner agencies visited and found concerns that these were actioned and there was partnership working. However we found no system in place to share information and learning with partners and collaborate for improvement.

The staff team and management team could not explain what processes or systems were in place for learning and improving.

We found there was culture where learning lessons from when things went wrong was not effective or embedded. We provided verbal feedback regarding our concerns, we revisited the service, and we continued to find concerns regarding poor record keeping, poor medicine management, hazardous products not securely stored, poor risk management, ineffective debriefs leading to a lack of learning, and good governance. This placed people at risk of continued poor practice. The provider continued to fail to put monitoring systems in place to ensure there was an effective oversight of the service in relation to care planning, daily recording, risk management and health and safe medicine management. This meant the provider had failed to ensure they had identified risks, concerns and had not improved the care provided.