St Helens Hall and 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

We assessed 1 quality statement from this key question. We have combined the score for this area with scores based on the rating from the last inspection, which was good. Our rating for this key question remains good. We found there was clear and effective governance processes in place which supported the delivery of safe care and treatment. A robust recruitment and induction process was in place to ensure staff received appropriate training, ongoing monitoring and were clear on their responsibilities.

This service scored 75 (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.

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 registered manager discussed emergency management plans and was able to identify where the business continuity plan was kept. She also discussed the systems in place to ensure there is learning from accidents and incidents and how this is shared. The registered manager outlined the induction and recruitment process which is used to ensure staff are suitably recruited and trained.

A robust auditing process was in place which ranged from daily walkarounds to monthly checks although there were a few gaps when daily walkarounds or audits had not been complete. Audits are recorded effectively on an online system which alerts staff when audits are due, overdue etc. ‘My home report’ was generated monthly covering all aspects of the home including number of deaths, number of DoLS (Deprivation of Liberty Safeguards), medication incidents, medicine reviews, infection control scoring and accident analysis and findings. Each of these categories were broken down into their own audits allowing the provider to have a more focused view and oversight of risk in the home. Through these internal audits, the regional and registered manager were able to highlight areas for improvement for example recruitment files. However, a medicines audit did not align with our findings which questioned the effectiveness of the audits. An induction programme of 12 weeks was implemented for new staff and agency workers which clearly outlines the objectives, core values and aim and expectations for workers. Included in the induction is an introduction to the organisational structure, an introduction to policies and log of competencies. This was monitored alongside a 6-month probation to ensure that staff were competent and suitable for the role. The comprehensive business continuity plan that was reviewed in April 2024 provided guidance and contingency plans clearly for staff to follow and implement.

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.