Saxby Lodge Residential 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

Systems for monitoring the quality and safety of the service had failed to identify shortfalls in standards. There had been a failure to make and sustain improvements over time. Not all staff were receiving the support they needed to be effective in their roles. Staff spoke positively about improvements at the service and described positive changes. People, relatives and staff spoke highly of the manager of the service and described a positive culture where people and staff felt able to raise any concerns.

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.

Staff described improvements in the culture of the home where they felt comfortable to raise any concerns. One staff member said, “We can speak up and raise any ideas at staff meetings.” Another staff member said, “It’s a more positive atmosphere now, we have more staff and the manager is very good. It’s a good working environment.” The manager described plans to make improvements in social engagement and had started to have conversations with people to identify their interests and preferences.

The provider had a statement of purpose which set out the vision and strategy for the home. This included aiming to provide a lifestyle which satisfied the social needs of people at the home. However, systems for assessing and reviewing people’s needs had failed to ensure people’s needs for social engagement were met. There was a lack of personalised activities available. Notes from staff meetings confirmed the lack of opportunities for social engagement was known and staff were discussing ideas to make improvements.

Staff spoke highly of the manager and described them as an approachable and validating leader. One staff member said, “They (manager) are always available in person or on the phone, always there for us.” Another staff member said, “The manager is very good at bringing the team together, manages really well, staff have respect for her, and she respects them.” Other comments included, “I think we are valued, there is always thanks and we are acknowledged.”

The nominated individual had applied to become the registered manager for the service. There were appropriate policies and procedures in place relating to the management of the service and the manager was knowledgeable about these.

Staff told us they were aware of the whistleblowing policy and knew how to raise any concerns if they needed to. One staff member said, “I would feel able to discuss anything with the manager.” Another staff member said, “The owner is very approachable, I could talk to them if I needed to.”

The provider had a policy for whistleblowing to support staff to speak up about any concerns.

The provider had recruited a diverse workforce. Staff told us they were supported to observe religious times and their cultural needs were considered and respected. While the staff we spoke to expressed that they were generally happy with the support offered, we found the provider had not meet the expected standard. Some staff, for whom English was not their first language, were not able to understand information provided, including about risks and how to manage them. They had not all received induction training or supervision to assess their understanding and ensure they could work safely and no additional support or adjustments had been considered.

The provider had policies to support staff including flexible working arrangements and diversity and equality policy and procedures. English was not the first language for some staff members. The provider had failed to assess the language needs of these staff and had not provided adequate support to ensure they were had the information they needed and that they were not disadvantaged in their roles.

The manager accepted shortfalls that were identified and took immediate actions to ensure people’s safety. They described improvements that were made as a result of safeguarding concerns but acknowledged there was further work to do in sustaining the quality of the service. Staff spoke highly of the manager and said improvements in the management of the service had already been implemented. One staff member told us about previous concerns that were now being addressed and said, “I feel confident now and see the changes as positive.”

There was a continued failure to make and sustain improvements in the quality of the service over time. Systems for monitoring quality and safety were not always effective. Shortfalls in the storage of medicines, management of risks of falls and fire safety had not been identified and addressed through audits and management quality control systems. A lack of management oversight meant that risks associated with recruitment, and the ongoing support of staff, had not been identified and addressed. Some measures were planned to address identified risks but had not been implemented. This meant the provider could not be assured that all staff were suitable and had been assessed as having the skills they needed for their roles. Staff competency had not been consistently assessed including for administration on medicines. Systems for ensuring confidentiality had failed to identify that paper records were not always kept securely and the proximity of the manager’s office to bedrooms meant that confidential conversations could be overheard.

People told us they knew who the manager was and described them as being approachable. People had mixed views about how the service was run. One person said the staff and the manager were all kind but they felt the service was not well managed. They told us, “It’s shambolic, it is not run in a precision way.” However, a relative described improvements and said the new manager had made a difference because they were open and honest about issues. They told us, “Communication has improved, there are more staff and it is generally better managed then it was.” They spoke about how the manager was working with health and social care professionals to ensure suitable placements were found when people needed to move on from the service. They told us, “The manager has developed a good rapport with all those involved, and I feel nothing would be done without seeking my input.”

Staff spoke positively about leadership at the service and described improved partnership working and communication. One staff member said, “We don’t get involved because the manager deals with all the other services but they communicate to us so we know what is happening and what is planned.”

The local authority were satisfied that the provider had worked with them to ensure safeguarding issues were addressed.

The provider had worked with the local authority to address safeguarding concerns and made improvements in safety and security at the service. We noted relevant information and advice from health and social care professionals was included within people's care records.

Staff spoke positively about improvements, one staff member said, “Things are a lot better, team work has really improved.” Another staff member said, “Things have changed, it used to be fraught working here but it is much better now.” The manager described their priority since becoming manager was in bringing stability and continuity of care and support to people, relatives and staff. They were open and honest about shortfalls that were identified and told us they were committed to making the required improvements following the inspection.

The provider had implemented some improvements since the last inspection, people were receiving adequate food and drinks and were being offered choices, and incidents of abuse were being reported. However, other shortfalls meant the service continued to be rated “requires improvement” and there were continued breaches of regulation. Systems to identify learning and make improvements were not always effective and this meant there was a continued failure to improve and sustain improvements over time. The manager described developing an action plan to drive improvements.