April 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

Systems to assess, monitor and improve the service were in place, however, audits completed by the management team were not always effective in identifying areas for improvement and we found ineffective oversight at provider level. For example, care plans and risk assessments were not regularly reviewed to ensure people received safe care that met their changing needs. The registered manager worked well with the staff team to help provide good care to people. Staff felt well supported in their roles and enjoyed working at the service. People, relatives, and staff were supported to raise concerns, and these were taken seriously and responded to.

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.

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.

The registered manager was clear about their roles and had the skills, knowledge and experience to perform their role. The registered manager felt supported by the provider. However, we found limited evidence to show the provider had carried out robust audits and processes. The audits carried out by the provider lacked detail and were mostly a tick box exercise.

The registered manager was visible within the service. Staff told us they felt supported by the registered manager. One member of staff said, “I know what is expected in my role and I have the support I need to carry out my tasks.” The registered manager told us, “I speak to the staff every day and we have a network of good communication and liaise with each other and MDT teams.” Another staff told us, “The manager listens and understands and is very approachable. I don't see them often because they have to manage the other homes as well but they are always available on the phone or if I ever need anything I will get in contact with them.”

Staff meetings were held. We reviewed minutes and saw they included information about the service as well as reminders about training. However, there were no action plans completed to evidence how issues raised were to be addresses, dates to be achieved and if actions had been resolved or remained outstanding. The registered manager sent surveys to relatives and people using the service to gather feedback about the service and discussed feedback with people who used the service.

Staff were positive about working at the service and promoting good outcomes for people. One member of staff said, ''I enjoy working here. We work well together as a team. I get a lot of support from the management.'' People we spoke with were complimentary of the service and staff. One person said, ''I can ask the staff for anything. They listen and are always here for me." A relative told us, ''My [relative] is well cared for and I always get informed if they are not feeling well or anything has changed. We have a good relationship with the home.'' Staff told us they felt confident to raise any issues with the registered manager and felt these would be addressed. One member of staff said, “I have regular supervisions approximately every two months. The supervision is usually with the manager and that is an opportunity for me to discuss anything with her that I need to talk to her about. We have team meetings every two months and they're also useful because management share any information with us that we need to know about. I have never had to make a complaint or raise any concerns, but I do know the management would listen to me if I had any issues. I've got full faith in them.”

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 quality assurance and governance arrangements in place were not always effective in identifying shortfalls at the service. Risks to people’s safety and wellbeing were not always being recorded, monitored and managed effectively. Although the registered manager had completed a monthly audit of care plans and risk assessments, these were not robust and did not identify the shortfalls found during this assessment. This meant robust processes were not in place to monitor the quality of the service, risks to people’s safety and maintain complete, up-to-date records in respect of the decisions taken about each person’s care and treatment. We found no evidence that people had been harmed however, effective systems to monitor and improve the quality of the service were not in place. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff told us they had supervision meetings and felt supported by the registered manager. Staff told us they had an induction when they first started and received ongoing support. One member of staff told us, “The manager is always available whenever I need to speak to her. The manager works across other homes too but visits here at least once or twice a week. I love working here. It feels like my second home. I love the residents and I love the people and I love the staff.”

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.