Shore Lodge - Care Home Learning Disabilities

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• 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

At this assessment we identified a breach of regulation relating to the oversight and management of the service. The provider had a governance structure in place to monitor the quality of their services. However, this had not been effective in identifying all the significant shortfalls found at this inspection. People were not supported following ‘Right support, right care, right culture’ guidance. The interim manager of the service did not understand the provider’s systems and did not have access to them all. The provider had identified some issues in September 2023, there had not been any improvements at the time of the assessment and some areas had deteriorated further. Healthcare professionals had requested actions to be taken around people's needs but this had not been completed after several months, placing people at risk.

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.

The management team told us they had only been working for the provider since summer 2023 and had inherited issues. However, the manager had been in post over 6 months and the operations manager for 5 months. Sufficient improvement had not been made in this time.

The management team were not aware of the provider’s strategic vision and how the service fitted into this. There was no evidence staff were aware of the provider’s direction for the service. People and their relatives had not been involved in collaboration to make sure future plans met their ongoing needs and wishes.

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.

The manager told us they did not have access to the provider's electronic monitoring and management recording system, so were unaware of how to access training information and performance indicators.

The provider’s own audits had identified areas that required significant improvement, however, monitoring systems were not effective. We found many actions proposed by the management team had not been completed. People continued to receive a service that was not safe and of a poor standard. Management oversight was lacking. The manager had an action plan which had been created following internal provider audits that highlighted improvements required. The actions identified were not completed and there had been no improvement in people's experience and better quality care. Many improvements identified as required by healthcare professionals and local authority commissioners prior to the CQC assessment and site visits had not been completed and we were not assured that they had been prioritised. Monitoring processes in place to check quality and safety had not always been completed, such as a managers daily walk about. This had only been completed 3 times in 3 months. A lack of oversight by the provider led to people receiving a service that was at times unsafe and was of poor quality. Opportunities had been missed to make improvements to the quality of life to people living at the service.

Relatives told us they felt the provider did not keep them informed of the involvement of other professionals. One relative told us “I do not have an up to date safeguarding report from KCC” and another mentioned the “GP has never come to visit [people] here”.

The manager told us they took a collaborative approach to maintaining partnerships with other professionals, to support people’s safety and quality of life. However, we found that advice given had not been followed, training provided by professionals had not been taken up by staff, and people had stopped attending local community day centres.

Visiting health and social care professionals told us they had given advice and suggested ways to improve to benefit the lives of people living at the service. Advice was not prioritised, and so timely action had not been taken. People continued to receive a less than adequate service. We were told staff had not been pro-active in referring people for healthcare advice. Although the service had recently received significant support from health care staff, this had not been at their instigation. Referrals were followed up as a result of concerns by visiting professionals referring people to colleagues.

Some people’s care plans were updated with advice given by heath care professionals. However, the recorded advice was not always followed, or staff were unable to follow due to lack of skills in aspects of people’s assessed care needs.

The manager confirmed she did not think there was a formal monitoring process for accidents or incidents.

A robust approach to creating a culture of learning lessons, listening, and continuous improvement had not been taken. Safeguarding concerns were not always investigated to learn lessons and make improvements. Monitoring systems were not in place to provide assurance all accident and incidents were recorded, and action taken to prevent a re-occurrence. There was no evidence the provider had processes in place to ensure continuous improvement and innovation within the management and staff team to strive for high quality care and support to people. Staff were not engaged in sharing ideas for improvement. A mechanism for learning from mistakes or incidents was not in place to support an open culture leading to staff investment in discussing new initiatives to enhance the service provided to people. We were not assured that all incidents which had potentially happened had been reported or recorded. A process for reporting and recording accidents and incidents was not followed. Incidents had not been monitored, to make sure staff had reported all incidents, and to identify themes, trends and analyse possible cause.