Delamere 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 service was not consistently well-led. Governance processes were in place, but these failed to identify and remedy the issues found at this assessment, for example around medicines, safety and infection control. The management team had failed to make improvements to cleanliness as recommended by a partner agency. This resulted in a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities). There had been recent management changes in the home and the manager was applying to be registered with CQC, however they left during this assessment. Interim management arrangements were put in place until a new manager could be appointed. The home was also supported by the Nominated Individual and provider. Although most people, relatives and staff gave positive feedback about the management of the service and the support they received, we also received mixed feedback. This included that there was not always a positive culture and people were not always spoken to with dignity and respect. People, relatives and staff were asked for their feedback, and this was used to develop the service. The provider was investing in new technologies to streamline working practices and improve oversight. After we fed back concerns, the management team made some immediate improvements, and told us they would prioritise addressing the other issues raised.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Management told us there was a shared strategy and vision, that supported a person-centred culture that promoted people’s rights. Some staff felt the culture was positive, proactive and person centred but other staff told us there was a culture where people were not always spoken to with dignity and respect and management were not always proactive. Management told us they had very few concerns or complaints raised about the home, they received mainly positive feedback and were responsive to any issues raised with them.

Processes were in place to support a positive culture. The provider set out its values and expectations of staff. However, we could not be fully assured that these were being met by all staff due to the mixed feedback we received and some of our observation of staff interactions with people. Staff did not always support people with their individual needs, especially during periods of distress.

Some staff fed back they had confidence in the manager and the management team and others raised that they did not think they were always listened to. A staff member told us they had raised some concerns about a person’s needs but no action had been taken.

Checks made by the management team were not always robust. They had not always ensured the home was safe, clean or that medicines were safely managed. There had been some instability in management arrangements in the last year. A new manager had been in post since February 2024 and was applying to be the registered manager. We received some positive feedback their relationship with most staff and partners. However, this manager left the home during our assessment. The home continued to be supported by the Nominated Individual and the provider. Additionally interim management arrangements were agreed to support to the home until a new manager could be appointed.

Most staff told us they now felt confident to raise concerns with the management team and these would be listened to and acted upon. A staff member told us they did not always feel listened to. The manager told us they asked for staff feedback and would address any concerns raised with them.

The provider had policies and systems in place, which aimed to foster a positive culture where people felt they could speak up and that their voice would be heard. We saw that where concerns were logged, they been investigated, and action taken to reduce risk.

The management team told us staff completed equality and diversity training and they employed and supported a diverse workforce.

Training, policy and procedures were in place to support equality, diversity and inclusion.

As highlighted in other sections of the report the oversight of the home was not effective and did not identify issues found at this assessment. The management team told us there was a quality assurance system in place and that they completed regular audits. They had identified some environmental improvements needed and these were on-going. They also told us they were implementing new electronic systems, which may not yet be fully up to date, as staff were updating these whilst also delivering daily care and support.

Processes were in place to check on the quality and safety of the service, but these were not effective. Audits had been completed covering key areas such as health and safety and infection control, but these did not identify the issues we found during this assessment. This left people at potential risk. The home used CCTV monitoring in communal areas of the home. Good practice had not always been followed in relation to this, for example, there was not clear signage telling people this was in use and some relatives we spoke with were not aware it was in place. The manager advise that signage had been taken down when the home was redecorated but had not been replaced. The home had action plans in place, but these focused on improvement to the decoration of the home and did not address all the issues we found during this assessment.

People and relatives told us managers were accessible and approachable.

Staff and the manager told us they worked in partnership with other agencies and professionals. The home had links with the local community, for example schools visited the home.

Partners told us staff and the manager were open to partnership working and they found them approachable. One visiting professional told us that staff knew people they supported well, were always able to answer questions and were responsive to any requests. Another had fed back to the home, “Your team has a great level of care and understanding on what's going on with each resident which helped with our clinical decision making as clinicians, so we could provide the best care to each of them.” Some partners told us that some improvements were needed in the home, such as around the environment, cleanliness, and nutritional recording.

Processes were in place to support working in partnership and with communities.

The management team told us they were investing in new electronic systems to manage care records, audits and rotas. This was intended to streamline processes and improve oversight. The provider was also testing a new digital fall monitoring system with a view to rolling this out to all homes.

There was investment in new systems. New electronic systems were in use, but we found there were some errors and omissions within these systems. Development plans were in place, but they did not focus on innovation or address all quality issues in the home