Clapham Lodge Care Home

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

At our last assessment we found widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The manager did not promote a positive and inclusive culture which promoted good outcomes for people. They did not understand their responsibilities to raise concerns and record safety incidents. The provider had not followed their responsibilities under the legislation and had not ensured that all significant events were notified to the Care Quality Commission. The provider had not ensured that effective systems and processes were in place to assess, monitor and improve the quality and safety of the service. Systems were not in place to demonstrate the service operated effectively to ensure compliance with the regulations. The provider did not have systems in place to receive or review feedback about the service effectively and had not used informal feedback to improve the quality of care provided. Following the assessment, we received assurances from the provider and a new manager was recruited. At this assessment we found improvements had been made. Improvements had been made regarding the governance, quality assurance and management of Clapham Lodge. However, some of the planned measures to quality assure the service had not been completed. The registered manager was aware of these shortfalls and told us they were committed to making improvement. The registered manager had a comprehensive plan of quality assurance checks which they had begun working through. They told us that these checks would be used to identify any areas of development and then used to create an action plan to drive improvement at the service. There was an open culture at the home and staff spoke positively about the level of support they receive from the registered manager.

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.

The service had a positive culture that was open and friendly. Staff at all levels were approachable and keen to talk about their work. A relative told us, “[Registered Manager’s Name] leads with passion and enthusiasm and never hesitates to interact or help with the Residents’ care. Staff are polite, professional and compassionate and it is obvious that they enjoy working with all the different characters that make up this happy home.”

Through observation and discussions with the registered manager, it was evident that they wanted to provide a good quality and person-centred service. They were aware of shortfalls within the service. For example, they told us they had a comprehensive plan of quality assurance checks which they had not yet completed. Throughout the assessment they demonstrated knowledge of the people living at Clapham Lodge, showing they had taken time to get to know them all individually.

The registered manager was in charge of the day to day running of the service. All staff spoke highly of the registered manager, however, some staff spoke of confusion regarding the role of the providers in the running of the service. For example, staff expressed a view that they would find supervisions and 1:1 meetings more beneficial if they were routinely carried out by someone they worked alongside on a regular basis, rather than one of the providers. Staff told us the registered manager was approachable and they were able to make suggestions for improvements, and that they were listened to. Relatives told us, “Since [Name] the new Manager started, the atmosphere in the home has changed for the better and so has the care.”

The registered manager understood their responsibilities to raise concerns, record safety incidents, concerns and near misses, and report these internally and externally as necessary. They understood their responsibilities under the legislation and ensured that all significant events were notified to the Care Quality Commission. We use this information to monitor the service and ensure they responded appropriately to keep people safe.

Staff were proud of the care they provided. Staff spoken with said they would recommend Clapham Lodge. They said they would be happy if a family member received care there. They also said they felt able to raise anything with the registered manager and felt they would be listened to. Staff told us they, “can give their opinion,” they, “can raise concerns,” and will be, “listened to.”

Effective processes were in place to enable staff the opportunity to speak up. The registered manager had a open door policy and made time to listen to staff. There were clear guidelines for staff to report internally and externally if they had any concerns.

The registered manager created an inclusive and respectful culture in the home and within the staff team. Staff told us how their individual needs around protected characteristics were respected. Staff with caring responsibilities had a pattern of work which enabled them to fulfil their responsibilities. Staff said they enjoyed working at Clapham Lodge and were proud of the improvements. They told us there had been changes within the staff team following the last inspection. They said, “The difficult staff are gone. Everyone gets on [now]. There is a happier staff team.”

There were policies and procedures in place around equality, diversity, inclusion and human rights. The registered manager was unsure if the policies and procedures were reflective of the service. They told us they had not reviewed the policies and procedures since taking up the post, however this was included in the plan for improvement. Staff had undertaken training in equality and diversity.

There was a management structure in the service which provided clear lines of responsibility and accountability. The service was led by a motivated registered manager. They were committed to providing a service that provided a good standard of person-centred care. We saw people and staff approaching the registered manager and vice versa. It was apparent that people felt relaxed in their company and that they were used to spending time with them. They knew people and their needs well. Staff told us, “There have been lots of changes with [Registered Manager]. Staffing levels improved. Policy and procedures now in place. Previously there was a lack of organisation. I can’t fault it now, the organisation is really good."

Some improvements had been made regarding the governance, quality assurance and management of Clapham Lodge. However, some of the planned measures to quality assure the service had not been completed and there was little evidence of lessons learnt. The registered manager was aware of these shortfalls and told us they were committed to making improvement. The registered manager had a comprehensive plan of quality assurance checks which they had begun working through. They told us they would use checks would be used to identify any areas of development and then used to create an action plan to drive improvement at the service.

People were part of the local community. The service engaged with external professionals to ensure people’s needs were met.

Staff worked well with external professionals and told us they would be confident to contact someone directly without hesitation.

Feedback from visiting professionals was positive. Visiting professionals described the registered manager as, “Extremely proactive,” and, “[Name] seemed extremely competent and experienced as a manager. [Their] knowledge of each and every resident and their medical issues and medications was extremely good.”

The registered manager was committed to building relationships with other organisations and the local community to improve outcomes for people. This included working with the local authority, GP’s and other NHS services.

Staff told us lots had changed since the last inspection and a range of improvements were made to the service. They said, “Staff are good now. People are now getting care. They have baths, get their nails done. Things have really improved.” Staff also told us, “A year ago I had many safeguarding concerns now it’s so much better. People weren’t safe, they are now. It’s all down to [Registered manager].”

The registered manager had a good oversight of the service. Changes were being made to communication channels and governance systems in the service which were improving the overall quality of the care people received. Some improvements had been made regarding the governance, quality assurance and management of Clapham Lodge. However, these improvements had not been embedded and some of the planned measures to quality assure the service had not been completed. The registered manager was aware of these shortfalls and told us they were committed to making improvement. The registered manager had an open-door policy and encouraged feedback from staff, people and their relatives. They were in the process of setting up regular meetings for people and their families, to formalise the process for people to share their views about the running of the service.