Nutley 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

Well-led - this means we looked for evidence that service leadership, management and governance assured high quality, person-centred care, supported learning and innovation and promoted an open, fair culture.

At our last inspection we rated this key question requires improvement. At this assessment the rating remained requires improvement. This meant the governance of the service was inconsistent. Leaders did not create a culture which consistently promoted high quality, person centred care.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider promoted a shared vision, strategy and culture. The registered manager and staff were open and honest throughout the assessment process. A relative told us, “The care given to the residents is excellent, the consistency of management and staff is a huge plus, with most staff being employed for many years.” The provider’s policies and procedures promoted an open and honest culture throughout the service.

The management team understood how to deliver care, treatment, and support and were open and honest. A relative told us, “(Registered manager’s name) is a wonderful manager, so approachable and nothing is too much trouble”. However, not all staff felt supported in a compassionate manner. Staff gave us mixed feedback in relation to if they felt supported and whether the management team was visible in the home. Comments included, “I feel (Registered manager name) could listen more to frontline staff”, and “I get frustrated with management apart from (Deputy Manager name) are not on the floor”. In contrast another staff member said, “I think they support staff well and they support me well.”

The provider was not able to provide evidence of supervision with the registered manager. However, the registered manager told us about the training they had recently enrolled in to increase their knowledge and skills, the provider supported this.

There were systems in place to actively seek feedback from staff and relatives, such as meetings, a website, an open-door policy, and messaging groups. We saw people and their relatives were involved with care planning and reviews. However, other methods had not yet been put in place to ensure fully effective, open, and safe feedback opportunities had been provided, such as regular surveys or appraisals.

We received some mixed feedback from staff in relation to feeling listened to. A staff member told us, “There is no confidentiality, I can never go to (registered manager name) for a problem.” However, another staff member commented, “(Registered manager name) and (Deputy manager name) are very approachable and you can go and talk to them.”

Relatives felt confident in raising concerns with the management team and felt they would be dealt with appropriately if concerns were raised. Records showed 1 complaint had recently been made, and the service had acted appropriately and in line with their policy.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. This included providing additional time off, and changing working hours/ days in recognition of staff members’ personal circumstances and responsibilities.

The service did not have clear roles, accountability systems and good governance. The provider continued to have ineffective governance systems in place to identify and drive improvements at the service. Leaders completed monthly audits but failed to identify the shortfalls identified at this assessment. Some improvements had been identified in relation to fire and the safety of the service, however, they had not been prioritised. Care plan audits did not identify people’s care plans were not always being followed and gaps in records in relation to people being supported to mobilise. They also did not identify missing mental capacity assessments. Fall audits did not identify the falls policy had not been followed, for example monitoring a person who had fallen. Following our last assessment, the service implemented a new recruitment system. However, this did not identify or ensure a full work history was obtained for all staff. These concerns placed people at potential risk of harm.

Whilst we did not identify anyone who had come to harm, ineffective monitoring contributed to the continued breach of regulation for governance.

The service shared information and learning with partners and collaborated for improvement, although 1 partner told us the service did not always participate with provider engagement forums. The registered manager told us they attended a local group, including other local care homes and GPs, to discuss best practice, such as the expectation of fall referrals, weight loss supplements, and improving communication. This group also gave time for networking opportunities between services. We observed the service involving the local primary school, people were engaged and seen to be smiling and laughing with the visiting children. A relative told us, “My mum particularly enjoys the weekly visits from children from the local school to read, sing and colour together.”

The service did not focus on continuous learning, innovation and improvements across the organisation. The provider had not ensured learning and improvement had taken place since the last inspection in relation to areas of concern that had been fed back to them. The registered manager was responsive to addressing the shortfalls we identified during the inspection. The provider also took urgent action to address safety concerns. Whilst we did not identify anyone who had come to harm, the lack of improvement contributed to the continued breach of regulation, in relation to a lack of improvements in areas such as consent, safe care and treatment, governance and recruitment. Following a recent complaint, lessons were learnt, and additional measures were implemented to ensure these concerns did not happen again.Some staff were being supported with courses to develop their health and social care knowledge. After the inspection the provider told us they had put a new fire alarm system in place and had fitted solar panels with a battery back up.