Dunraven House 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

The provider and the registered manager had failed to bring development and innovation to the service which meant it was not being run in line with current legislations and best practice. People were not always being encouraged to engage in their community and there was no consideration given by leaders on how to maximise people’s skills and independence.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke to did not know what the aspirations and direction of the service was. They could not identify any innovative plans for service development. The registered manager told inspectors that they had a mission statement but staff could not identify what or where it was, nor what the provider’s ambition for service delivery was.

The provider had not ensured there were processes in place to ensure the service was developed or changed in line with current national expectations of person-centred support. The model of care being provided was not suitable for people with a learning disability or autistic people and was not in line with Right Care, Right Support, Right Culture.

Some staff felt the registered manager and other managers were not approachable and did not always listen to them about issues or concerns. Other staff told us they could speak to some members of the management team; however, they felt the registered manager was not approachable

The provider had processes in place such as team meetings and supervisions however these they could not demonstrate that these were facilitated regularly or that they were effective.

All staff were employed on zero-hour contracts. Some staff told us because they were on this type of contract, they were concerned that if they spoke out about things they had witnessed such as poor practice, they would not be given hours the following week. This meant staff had not always been confident to speak out when they saw poor practice. One member of staff said they witnessed poor practice by the registered manager and felt they had no recourse within the service to report this. Some staff told us when they had spoken up to managers, for example, about how peoples’ money was being managed, their concerns were not addressed by the registered manager or the provider. However, other staff felt they could take things to the management team and that they were listened to.

There were processes in place for people and staff to speak up, however some staff said they would not follow these, while others said they were not listened to when they spoke out.

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 said they did produce their aims which were pinned up in the service. However, staff we spoke to did not have an awareness of the service’s direction and development. We addressed this with the registered manager who said they would talk about their direction with staff in their next meeting.

Auditing processes were in place, but they were not always effective at identifying issues within the service. For example, an internal dignity audit conducted by the provider failed to identify any issues with how the service was promoting people’s dignity. Regular provider medicine audits were carried out. We saw examples of these and that actions had been identified and acted upon. However, no external pharmacist assessment visits had taken place for some time. We discussed this with the registered manager, and they said they would contact the pharmacy to see if they could recommence. The registered manager had a process in place for safeguarding but had not properly identified the thresholds for reporting issues to the local authority and the CQC. This meant the process was not effective.

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.

The provider could not identify any innovations or improvements they had introduced to develop the service. Staff also could not identify any innovations that had been introduced when we spoke with them. Learning was not promoted nor sharing when things had happened previously.

The provider had no process for developing the service, for bench marking against similar services or ways to identify improvements to ensure the service was delivering person-centred care and support to people. This meant the model of the service had not changed for several years and people were not being supported in line with current best practice guidelines and legislation.