Conifer Lodge Residential 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

Staff were clear about their roles, responsibilities and accountability. They were positive about the support they received from the management team. The provider had systems in place to assess, monitor and mitigate risks. Some of these needed further strengthening by the provider. We were not sufficiently assured that staff deployment and numbers were correct for people’s needs and safety. Following the assessment feedback the provider added 1 extra care staff for the late shift. For staff recruitment; there was no evidence of oversight by the registered manager or provider to ensure all required checks were clearly completed as required. The provider’s policies reviewed showed these were in date and reflective of current best practice guidance and legislation. The registered manager and provider were open and honest during this assessment and were responsive to shortfalls identified and took immediate action.

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.

Staff were clear about their roles, responsibilities and accountability. They were positive about the support they received from the management team and described both the provider and registered manager as very approachable and responsive. Staff said they felt teamwork was good. A staff member said, “I look after people and treat them as I would my mum and dad, I get close and protective.” Another staff member said, “The management team are lovely, approachable and very supportive.” Staff confirmed there was support available at all times throughout the day and night. These calls were always picked up and responded to.

The provider had systems in place to assess, monitor and mitigate risks. Some of these needed further strengthening by the provider. Shortfalls in governance procedures included supplementary care records such as some gaps in the recording of care provided. However, no person had come to harm as a result of this. The registered manager told us of actions they had taken to make improvements - a daily recorded monitoring check by team leaders and a weekly audit by the registered manager. We were therefore not sufficiently assured that staff deployment and numbers were correct for people’s needs and safety. Following the assessment feedback the provider introduced a new shift pattern from 4pm to 10pm of one additional care staff on duty at this time. Incidents showed that in March and April 2024 that falls had occurred in communal areas that were unwitnessed, despite the registered manager and staff stating staff were required in communal areas at all times. This was raised with the registered manager. Evidence reviewed showed the frequency of staff supervisions were not as the registered manager had stated was expected. However, staff clearly felt well supported and we observed this. There was no evidence of oversight for staff recruitment to ensure all required checks were clearly completed as required. The registered manager then took immediate action and implemented a new checking system. The provider, registered manager and team leaders completed weekly and monthly audits and checks. This included unannounced spot checks on staff, checks on health and safety, environment including equipment, fire, medicines management, and monitoring of staff training and development needs. The provider’s policies reviewed showed these were in date and reflective of current best practice guidance and legislation. The registered manager and provider were open and honest during this assessment and were responsive to shortfalls identified and took immediate action.

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.