Shore Lodge - Care Home Learning Disabilities

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

Leadership of the service was inadequate. There was a closed culture which was not person centred. A closed culture means a poor culture that can lead to harm, which can include human rights breaches such as abuse. Processes to keep people safe were not in place. People experienced institutionalised neglect, their distressed behaviours were ignored and not acted upon to ensure people were safe and felt safe. People's human rights were not upheld. Quality monitoring systems were inadequate. There were widespread failures by the provider and the registered manager to assess and act on risk. The provider and the registered manager had not been open and honest in line with their legal responsibilities. They had not shared information with CQC or with stakeholders. People and staff were not encouraged to speak up, and when they did, they were either ignored or bullied and threatened by the provider. At this assessment we found a continued breach of regulation relating to the oversight and management of the service. The provider had failed to act on the warning notices issued following our last assessment.

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.

We found the culture within the service had not improved since our last assessment in March 2024. We saw a member of staff eating food directly in front of a person while they were sitting on their own together in a conservatory area. The person was sitting in their wheelchair and was not able to communicate verbally. The person did not have any food of their own and it was near lunchtime so they may have been hungry and unable to communicate this. This was not respectful or inclusive behaviour by the staff member. We told the registered manager and a senior manager about this and asked if the staff member had been told they could eat their food at this time and in this way. We were told the staff member had not been advised to do this. We continued to identify a closed culture. We received concerns from whistle blowers before this assessment and during the assessment process. Whistle blowers told us they felt unable to raise their concerns with the management team as they had not been listened to when they had previously or were told to “zip your mouth” and their jobs were at risk if they raised issues as the service would be closed down. We were told there was a closed culture and that some staff “targeted” other staff if they raised issues about how they provided care to people. We told the registered manager and a senior manager about these concerns during the assessment visit, but we continued to receive similar concerns after this.

The provider had a service improvement plan in place, however, there was no evidence this process had tackled, or started to tackle, the poor culture at the service. People were not stimulated with activities that provided them with a meaningful day. People did not go out regularly and when they did, the pursuits were the same each time. For example, to a shopping centre, or to fast food outlets or a garden centre. People were not supported to engage in things that interested them individually or provide them with opportunities to try new things. There was no evidence of staff speaking up for people and advocating for them to have a better life.

Although some staff said the managers were approachable and they received good support, other staff told us they did not find the management team caring or compassionate. They said they were not listened to and were deterred from raising issues about people’s care. There was a detrimental impact on staff who had raised concerns and had found no action was taken. People were not safeguarded from abuse as staff and leaders did not exercise their responsibilities in safeguarding people in their care.

There had been changes in the management team which meant there was little consistency and staff were responding to different management styles. The registered manager had been absent for some months and an interim manager had been in place. When the registered manager returned to work, the interim manager continued to be in their interim position for about 6 weeks. There had been conflict at times. This was evident from what staff told us and by the notes of a staff meeting that ended in conflict between managers. Examples of poor culture affecting the quality of people’s care went unnoticed. We shared our concerns around our observations of poor culture amongst staff members at the last assessment and we saw no improvement at this assessment. We had cause to raise further concerns of poor culture involving the same staff members with senior leaders at this assessment. Thorough investigation was not always been undertaken to determine the role of staff during incidents and if themes had occurred that needed further investigation. Decisions around action to take had not been made quickly to ensure peoples continued safety following incidents. The registered manager told us they did not always believe staff members accounts of some incidents and said some provider investigations had not gone far enough in probing further into staff accounts that did not add up.

An open and honest culture was not apparent among staff and leaders. Staff told us they were very worried about raising concerns about poor care openly as they may be “targeted”. Staff said when they did raise issues they were told to “zip” their mouths by members of the management team. They said they were told the service would be closed down if too many issues or incidents were raised. This led to a closed culture where we could not be assured people were safe as staff did not always report incidents or call out poor care.

Processes to ensure staff understood their responsibilities to share concerns were inadequate. Some staff had shared concerns outside of the service, with CQC. However, they wished to remain anonymous as they were very concerned about the repercussions on them if they were identified. They feared bullying and also losing their job. Although we told members of the management and leadership team about concerns raised, and that we had identified a closed culture during our last assessment, the provider failed to take action and a closed culture continued within the service. A senior manager told us they were dismayed staff were raising concerns with CQC as they had tried to address culture by holding a “listening event”. The event was a staff meeting that ended in conflict between the management team, some of whom were swearing and one had walked out. The provider missed opportunities to learn from incidents, openly share learning with staff and make sure staff understood and felt safe to act on their responsibilities in safeguarding people.

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.

There had been management changes within the service that had encouraged a level of uncertainty with staff and meant the positive and skilled leadership necessary to make the necessary improvements were lacking. The provider had not recognised the serious level of concerns within the service, even though these had been clearly highlighted following the last assessment in March 2024. A service improvement manager from the provider’s service improvement team had been allocated the service to support improvements. However, this intervention had not supported the swift action that was needed to ensure people had a better and safer life.

Governance continued to be inadequate. The failure by leaders to have effective processes in place to monitor the quality and safety of the service had a major impact on people's lives: people had been harmed. We served 3 warning notices following the last assessment in March 2024 for regulations 11, 12 and 17. At this assessment, we found the provider had not made improvements and therefore had not complied with the enforcement action and was still in breach of these regulations. The provider’s service improvement plan had not driven improvement as it should have done. Areas had been marked as complete, when we found ongoing issues, and this had not been picked up. The provider’s compliance team had completed an audit in January 2024. The compliance officer had identified improvements were needed during this audit and had rated the service “requires improvement”. Despite this, and despite the serious concerns we found in March 2024, the compliance team did not return to check on progress until the 2nd day of our assessment visit, 25 June 2024. Areas of the service improvement plan had not been addressed, had not been found and rectified as quickly as possible by the provider. We continued to find concerns in relation to the assessment and mitigation of individual risk, people’s safety, the reporting of incidents, people’s human rights under the MCA, staff training, a poor and closed culture and lack of clear management oversight and leadership.

Staff told us people were not supported to be part of their local community or given opportunities to try and learn new things and develop partnerships to enhance their life. They said people did not have the opportunity to go out every day, and some people did not go out at all in a week. When staff did take people out it was based on what was easiest rather than what was the best for each individual.

Partners in people’s care, such as health and social care professionals did not have faith in the staff, management team or provider in making the improvements advised by them and necessary in a timely way. The feedback we received was clear that advice had been offered about many aspects of people’s care, such as the equipment they used to make their lives better, or their oral health. The healthcare professionals giving the advice were not assured advice was being taken on board, or actioned.

Processes to ensure advice given by health and social care professionals was implemented were not effective. Advice and guidance had been given in relation to people’s health, equipment to enhance their comfort, safety and ability, and how to engage people in meaningful activities had been offered but not taken up by staff.

Staff told us incidents were not always reported. They told us staff were discouraged from reporting incidents as this would place the service under scrutiny by external stakeholders such as the local authority and CQC. Staff told us about incidents that had happened and not reported.

There were ineffective processes in place to ensure accident and incidents were reported, fully investigated and lessons learnt to prevent further similar occurrences and keep people safe from harm. Incidents had happened between people where people were seriously harmed. Lessons had not been learnt as similar incidents had happened previously but had been allowed to happen again as people’s individual risk assessment and prevention plans had not been in place. Timely action had not been taken to ensure investigation into serious incidents had happened swiftly and robustly to keep people safe from ongoing harm.