South Haven Lodge Care Home

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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

We assessed 5 quality statements within this key question. We found 1 breaches of the legal regulations in relation good governance. The breach relating to good governance was a continued breach of regulation and had been identified at the last two inspections. South Haven Lodge Care Home has been rated required improvement within the Well Led domain for the last 2 consecutive inspections completed by the Care Quality Commission (CQC). The provider’s governance systems were inadequate and failed to recognise a range of shortfalls in people’s care and the service. There were not effective systems in place to assess monitor and improve the quality and safety of the service. The was a lack of robust oversight from the provider and checks of the quality of the service were not being consistently completed. Actions had not been taken to address previous shortfalls that had been identified by stakeholders, professionals and CQC.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Following discussions with staff and leaders we could not be assured the registered manager and senior leadership team recognised that a closed culture had developed at South Haven Lodge Care Home or act to prevent it. Closed cultures mean people are more likely to be exposed to risks of abuse, avoidable harm and breaches of their rights under the Human Rights Act 1998 and the Equality Act 2010. The provider and registered manager failed to identify that a lack of action by members of staff to respond to people’s needs and their failure to effectively manage anxieties and frustrations demonstrated by people had created a closed culture at the home.

All new starters are provided with a ‘Welcome to Aurem’ booklet upon commencing in post which set out the vision and values of the service. Additionally, staff had access to an ‘Employee Engagement Platform’ which provided information to staff on the providers vision and values and gave them the opportunity to share good practice. However, although these were in place from our observations and discussions with people, relatives, staff and professionals we could not be assured these visions, values and shared direction was adhered to. There was a lack of evidence of any robust auditing or oversight of people’s care to ensure all people had the same opportunities and care records, observations and discussions with staff and people demonstrated people did not always receive person-centred care. There was evidence to suggest people received institutionalised care that was more to benefit the staff daily routine as opposed to people being treated as individuals. The provider failed to recognise they had developed a culture that did not robustly promote or uphold people’s rights.

At the time of the assessment visits people, relatives and staff generally spoke positively about the registered manager and described them as supportive. However, we did receive mixed views about the wider management team. All but one staff member we spoke with felt undervalued by the organisation. A staff member told us, “I’m not really valued [by senior leaders]. We have people from head office come in but not often and usually only when there is an issue. They don’t talk to us [staff].” Another staff member said, “The senior leadership team don’t interact with us [staff], when they do visit, they don’t even speak with us. I did do a survey a couple of months ago online, but nothing is ever done. I have told them time and time again we don’t have enough staff, but they don’t take any notice.” A third staff member said, “The provider doesn’t care about the people or the staff. I don’t feel at all valued.” Following the assessment visits, we discussed the concerns raised by the staff with a representative of the provider. The provider’s representative was disappointed about the staff feeling undervalued and confirmed actions would be taken to improve staff morale.

Evidence showed senior leaders at all levels did not understand the context in which care needed to be delivered in a compassionate and inclusive way. We could not be assured leaders had the necessary skills and knowledge to ensure people were provided with continued effective and safe care to people. At the time of the assessment visits, we discussed the registered managers processes in relation to completing audits in relation to medicine management, care planning, risk assessments, daily records and monitoring of people’s health needs. The registered manager told us they were not ‘allowed’ to audit these areas as they were not clinically trained, and this was the responsibility of the clinical lead or nursing staff. The registered manager and the clinical quality manager for the provider, both confirmed they were unaware if these audits were completed to an appropriate standard or if any actions from the completion of these audits were identified and addressed. The registered manager and providers clinical quality manager was unable to confirm who was response to check these audits. The registered manager told us they completed and shared weekly reports with head office to keep them updated on the current position of the service. On review of these weekly reports, we could not be assured these were reviewed by staff at head office. For example, for one question on this form the registered manager had noted ‘Not sure what this means?’ every week for 7 weeks. We could not find any evidence to suggest the meaning of this question had been discussed with the registered manager to allow them to answer this question effectively. Therefore, we could not be assured effective oversight of the service.

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.

At the time of our assessment visits the service was undergoing a period of change in relation to the manager of the home. The registered manager in post at the start of our assessment left the service on the 4 October 2024 following working their notice period. A new manager had commenced employment at the home on 30 September 2024. From discussions with the registered manager, we could not be assured they had a clear understanding of their own, members of the senior leadership team and the clinical leads, roles, responsibilities and accountability. For example, the registered manager told us, they were not permitted by the providers to complete specific audits, however they were unable to confirm who was responsible for ensuring these audits were competed to an effective standard to ensure safe and effective care was provided to people. This was discussed with a representative of the provider following the assessment visit. The provider’s representative was able to share with us an audit they had completed in January 2024. Although this audit contained details of the environment and demonstrated they had spoken with people and relatives about their experiences there was no evidence to suggest there was provider level oversight in relation to people’s immediate care needs and treatment. Therefore, we could not be assured there was effective registered manager and provider oversight. The staff spoke highly of the registered manager and described them as supportive and understanding. On our final assessment visit we spoke with the staff about the manager and their comments included, “They [manager] seem firm but fair”, “They have already made some changes, which makes lots of sense” and “They [manager] seem good, I think it is going ok.” However, as this manager had just started in post it was too early to check the effectiveness of any changes to systems and processes they had made.

The provider’s governance systems were inadequate and failed to recognise a range of shortfalls in people’s care and the service. There were not effective systems in place to assess monitor and improve the quality and safety of the service. We identified concerns in the management and mitigation of risk. This included ensuring people received food and fluids of a consistency they could safely manage, promoting skin integrity via regular repositioning and lack of systems to ensure appropriate numbers of skilled and competent staff were in place to meet people’s needs safely and effectively. There were not robust processes or systems in place to ensure appropriate numbers of staff were available to meet people’s needs. The service worked on a ratio of one staff member to 5 service users, this did not consider people’s individual and specific needs. The systems in place to help ensure staff were appropriately trained were not effective. The registered manager and provider had failed to recognise staff did not have appropriate training and skills to meet people’s needs. There were no systems in place to ensure ongoing monitoring of staff practices were completed to help ensure care was provided as required and in a safe and effective way to meet people’s needs.

Multi-disciplinary meeting were completed weekly at the home which supported people to access health and social care support in a timely way. People’s care records demonstrated they had access to health checks such as dentist, opticians or chiropodist. “A person told us, “They [staff] will call the doctor for me if I need them to.” A relative said, “[Person] has had need for GP visits for infections, has met with psychologists, psychiatrists and physiotherapists towards better managing their longstanding mental health and mobility issues. The nursing team at South Haven Lodge are very proactive in this area.” We received mainly positive comments from relatives in relation to their involvement and inclusion in decisions about people’s care. A relative said, “The staff are lovely, caring and are always available if I have any questions” and “I am kept up to date with any changes in person’s health.” Another relative told us, “They [staff and management] listen, I have meetings with them, and we also have relative meetings, I’m very satisfied.”

Staff and management said they worked closely with health and social care partners and referred people to external health specialists for support and guidance where required. However, we found examples where this had not consistently happened. For example, staff had failed to act when advice and guidance previously provided by a professional in relation to how staff should support a person to mobilise became unsafe due to the person’s changing needs. Staff failed to identify this or sort support in a timely way to ensure ongoing safety to this person. Additionally, we could not be assured specialist support and advise in relation to the management of pressure areas and wounds was requested in a timely manner or that advise, and support given was followed. The registered manager and staff did demonstrate efforts had been made to become engaged with the local community. A staff member told us, religious services were held at the home and members of the community were invited to events at the home including coffee mornings and barbeques.

Part of our assessment was triggered due to feedback from health and social care professionals raising concerns about the service. These professionals were concerned that despite providing support and advice to the provider and staff over several months, there continued to be a lack of improvement in the quality of care. During our assessment the management team told us they worked collaboratively with partners to ensure people were provided with effective and safe care. However, we received mainly negative feedback from professionals in relation effective partnership working, learning and working in collaborative to drive improvement. A healthcare professional told us, “We are having lots of issues with prescriptions, double requests and requests for odd numbers of tablets” and “I am not aware of who the manager is.” Another professional said, “The previous registered manager and clinical lead were amenable to working collaboratively but it was difficult to move forward and develop an open working relationship when corporate would override some clinical decision making.” A third healthcare professional confirmed weekly ward round were completed at the home which allowed people’s issues to be raised in a timely and effective manner. However, they added, “We are still called most days for minor ailments, referrals and medication issues which arise due to poor coordination of operational processes, lack of communication in the team and poor clinical acumen.” During our assessment we also received concerns the provider and staff didn’t not always following best practice advice and support offered. For example, one person was assessed by a healthcare professional as requiring repositioning every two hours to promote healing of pressure wounds and prevent further deterioration to skin. However, this advice was overruled by a staff member employed by the provider who felt repositioning the person every 4 hours was acceptable.

Although we identified there were systems and processes in place to allow effective engagement with external partners and professionals, we could not be assured these were used appropriately or in a timely way which benefitted people and improve their experiences of care. The provider did not demonstrate insight into the risks or could not produce evidence that there were effective audits completed or detailed action plans had been developed to address the identified risks. The provider failed to act on areas for improvement identified by external agencies including, health and social care professionals as well as safeguarding teams and quality improvement teams provided by the local authority. The provider failed to act to make effective improvements following CQC’s findings at previous inspections. This exposes people to the risk of harm because the provider had failed repeatedly to act to make improvements and work with external partners to improve the service and mitigate the risk of harm to people. Following this assessment an action plan was developed by a representative of the provider detailing the concerns, and action they would take to implement improvements.

Staff had not received clear guidance in relation to mitigating known risks to people. Some staff demonstrated they lacked understanding of people’s needs and how to support people safely considering their specific risks. Staff were unable to demonstrate past incidents or near misses experienced by people were considered to mitigate and minimise future risk of harm.

In the month prior to our assessment the provider had engaged a private consultancy company to complete an independent external evaluation of the service. Although this engagement demonstrated the provider had taken some action to establish the current situation in relation to all aspects of the service, on review of the service improvement plan developed, we could not be assured improvements would be effectively implemented. There were not effective governance processes and audit systems in place to help ensure the safe running of the service. Without these the provider was unable to identified issues and concerns in a timely way and acted on these. The auditing systems that were in place for identifying, capturing and managing organisational risks and issues were ineffective and did not drive improvement. The concerns we found on day one of this assessment visit were shared with the registered manager, however on subsequent visits and on review of records received following our visits we continued to find similar concerns. This placed people at continued risk of receiving unsafe care and treatment. We also found records in relation to accidents, incidents and near misses did not demonstrate these had been fully investigated and reviewed to help mitigate future occurrence. Although there was evidence quality assurance questionnaires were provided to relatives and people we could not be assured action was taken when issues were shared. Additionally, a representative of the provider had completed an audit of the service in January 2024 and noted, ‘there is potential to improve mealtime experiences', however at the time of our assessment there was no evidence to demonstrate any action had been taken to address this. Following this assessment a detailed action plan was developed by a representative of the provider detailing the concerns, and action they would take to implement improvements.