Derwent Lodge Nursing 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

The management team maintained a positive culture. Governance and management systems were in place to drive improvements. This included a range of audits which were undertaken regularly to monitor, review and improve the service people received. Staff were positive about their roles and told us they felt supported and knew how to seek advice, guidance and support.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were positive about their roles and told us they felt supported and knew how to seek advice, guidance and support. We had received feedback the new management team had impacted the service positively, staff felt there was more attention to detail with checks and audits being undertaken regularly. Staff felt their contributions were taken on board and acted upon.

The management team maintained a positive culture. Governance and management systems were in place to drive improvements. This included a range of audits which were undertaken regularly to monitor, review and improve the service people received. The auditing process fed into a service action plan and was reviewed by the regional manager.

Staff spoke positively of the registered manager. One staff said, “She's there not only for the residents but for staff also. If we have any problems we go to her.” Staff wanted to share they appreciated the incentives brought in by the registered manager, this boosted staff morale and acknowledgement for staff’s hard work and staff felt valued. Another staff member said, “Managers are all supportive and have been compassionate with some of our own support requirements”. The registered manager felt supported by their line manager and their feedback included the work that had been undertaken to upskill the workforce in leadership positions to undertake audits and contribute greatly to the governance structure. Feedback from the regional manager included recent thematic work that had been undertaken, understanding the issues, looking at improvements and rolling out those improvement actions not only in the service but provider wide as well as the regional manager sharing good practice and improvements from other services for best practice.

There was a clear staffing structure. Managers and staff understood their individual roles, responsibilities, and the contribution they made. We found there was an open culture within the service. The registered manager and staff were open and honest with us throughout the assessment. The registered manager had a clear vision and was committed to providing a person-centred responsive service. Staff we spoke with shared this commitment. There were monthly clinical governance meetings; which promoted consistency across the provider’s services and facilitated sharing of lessons and good practice. The provider arranged training and shared information to promote inclusion and diversity.

Staff we spoke with shared they would not hesitate to share with the nurse in charge or the registered manager any concerns or to raise a whistleblowing concern they had. Staff fed back the manager is present and felt they could approach the manager and felt they would be listened to.

The provider had a robust whistleblowing policy in place, along with the local safeguarding team and Care Quality Commissions contact details for staff as well as visitors. The topic was also discussed regularly at team meetings and at staff supervisions. The provider had an email facility for staff to reach out to the provider directly to raise any concerns.

Staff spoken with were complimentary of the management team and shared they felt supported and valued. The provider supported sponsorship placements and staff felt welcomed into the service, supported and felt part of the team.

The provider had robust policies and procedures to support workforce equality, diversity and inclusion. The provider undertook regular team meetings and supervision of staff to include obtaining staff feedback as well as people and their families feedback in quality monitoring processes.

The registered manager told us there were a number of checks and audits in place to monitor and improve the service. Staff were positive about the leadership of the management team. Staff told us they felt supported in their work and enjoyed working at the service. Staff told us they were able to speak up and express their views. Comments included, “My manager is very open and supportive”, “We work well together. There is an open-door policy, and the registered manager is approachable” and “The managers door is always open; she is hands on and visible on the floor too."

There was a clear management and staffing structure where each staff member knew their roles and responsibilities well. Statutory notifications were submitted to CQC as required. Head of departments, for example, chef, maintenance person, activity person and housekeeping, met regularly to discuss service matters. This promoted accountability. There were regular staff meetings, including clinical risk meetings where the senior staff and nurses discussed issues which benefitted outcomes for people.

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.

Feedback from the registered manager included, “I often conduct regular meetings to discuss lessons learnt, depending on the nature of the lessons learnt, if it is a group learning or an individual learning, I will often conduct group supervisions/discussions on findings and actions to take to prevent it happening again, these are then signed and held in staff files. If it is an individual case, I have completed reflective discussions, followed HR proceeding and provided additional training where required. I have previously submitted several serious injury notifications; this was an indication to me that further training was required, therefore I sourced additional training ‘react to red’ and made mandatory for all direct care staff to complete, this has drastically reduced the level of skin integrity issues that were occurring."

The provider had processes in place to support continuous learning and improvement and contributing to ongoing action plans which were fed from regular auditing, feedback from people and provider led continuous improvement strategies.