Downshaw Lodge

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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

We identified a breach of the legal regulations. Since 2022 administrators have been responsible for the management of the service. Further management changes were being made following the departure of the registered manager. Governance systems were in place however these were not sufficiently robust to address areas of improvement identified by managers and those identified during this assessment. The service also identifies as a complex dementia care service however this is not reflective of the service provided. It was recognised the service needed a period of stability so systems providing clear management and oversight of the service could be implemented and embedded. Managers were working closely with relevant agencies to make the necessary improvements.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

It was acknowledged by both managers and staff the service had and was going through a difficult period due to the home being in administration. The regional manager had recently met with staff, people, and their relatives to provide an update in relation to current plans. Staff spoken said the current financial position and uncertain future of the home had impacted on morale but were committed to supporting the service and the new manager. Staff hoped this would provide more stability and direction with regards to the long term future of the home.

The aims and objectives of the home were outlined in the statement of purpose and service user guide. The documents needed to be reviewed and updated. The service user guide outlined what people could expect from the service. However, these were not always delivered in practice, such as involvement in care planning and regular resident and relative meetings. The regional manager was aware that systems and process needed further development and embedding. It was anticipated these would be addressed by the new management team commencing November 2024.

Staff spoken with felt supported by the current management team. However, were looking forward to the new manager and clinical lead commencing their employment. Some staff spoke with felt this would address some of the inequality in workloads and help to develop better teamwork.

The service is currently under administration. The management team had been proactive in recruiting and appointing a new manager following the registered managers departure in August 2024. Systems to support effective and inclusive leadership needed further development with the implementation of more formal communication channels with staff, people, and their relatives, such as staff meetings, relative and resident meetings, feedback surveys, and more robust governance systems. Whilst some audits had been undertaken as part of the quality assurance process these had not been effective in identifying the areas of improvement found during this assessment.

Staff were aware of the whistle blowing procedure and said they felt able to speak with the regional manager and interim manager should they need to and were confident any issues would be acted upon. Staff felt the introduction of the new manager would offer better stability and help to improve morale within the team as well as address issues in relation to some staff practice.

Staff were provided with a copy of the homes handbook. This outlined the policies and procedures in place including the whistleblowing/speak up policy. This outlined who staff could speak with in confidence, alternatively they could see support through the company whistleblowing helpline. Opportunities to seek feedback from people and staff were not formally embedded, such as feedback surveys, regular meetings, and individual supervisions. These systems help to promote a positive culture where people feel they can speak up and are confident they are listened to.

Staff spoken with said morale was improving however felt teamwork could be improved so that equal responsibility was shared amongst the team. Staff were optimistic this would be addressed by the new manager providing a more equitable working environment and enhance the well-being of staff further.

A staff handbook was provided to all staff. This outlined what was expected of staff as well as their employment rights and how they would be supported. This included staff well-being and flexible working arrangements. The service had an equality diversity policy, which outlined the aims of the service, creating a culture that respects and values each other’s differences, and promotes dignity, equality and diversity. Records showed 95% of staff had also received training in equality and diversity.

The regional manager said as part of their on-going review of the service it was recognised improvements were needed in some of the senior roles providing better leadership and clinical oversight of the care and support provided. Following the departure of the registered manager in August 2024, the regional manager had been proactive in securing a new appointment along with further clinical staff. Staff told us they understood their roles and responsibilities and who they reported to. Staff said they felt comfortable speaking with the regional and interim managers should they have any issues or concerns. Staff were aware of further changes in management, however said they were looking forward to the new manager commencing. All felt this would offer better stability and support to people and staff.

Robust systems were not in place to monitor and review all areas of the service, helping to identify the issues identified during this assessment process. A schedule of audits and checks had been identified however not all had been completed as planned. For example, 10% of care plans were to be reviewed monthly, however there was no audit completed April, May, August, and September. Monthly resident of the day/dignity audits had not been carried out and quarterly clinical governance audits had not been completed for May, July, and August. In addition, systems to help protect people and uphold their rights were not sufficiently robust. Records showed the regional manager had carried out regular reviews of the service between June and September 2024. Areas of improvement were noted with regards to care practice, medication, record keeping and training. This information had been used to inform the home’s improvement plan. Whilst findings had been discussed with the team, we found improvements in practice had not been made, work was still required to improve the systems and processes as well as the standard of care and support people wanted and needed. As part of the business improvement plan, work had been identified to improve the standard of accommodation provided for people. Due to the service being in administration, the release of finances to fund the work needed formal agreement. Policies and procedures were in place to guide and support staff. However, these were not always followed in practice to ensure best practice was followed. Our findings demonstrated a breach of regulation 17 regarding good governance.

The service worked in partnership with other health professionals within the community to ensure safe care and treatment for people living at the home.

The regional manager recognised the need to be open and actively seek support from other agencies when needed. The home had been working closely with the local authority commissioning and safeguarding teams to address areas improvement in service delivery. It was acknowledged improvements were required across the service however accepted there were some constraints due to the service being in administration.

Multi-agency concerns meetings, involving the local authority, were being held on a bi-monthly basis. The purpose of these meetings was to help monitor and share information and events about the home. Other partner agencies told us they were involved with the service. These included the local authority quality improvement team and the health protection team. Following a recent infection control inspection the home had been rated 98% compliant.

The business improvement plans incorporated information from partner agencies to help drive improvement, this included opportunities for additional staff training to support and develop the team in best practice.

Staff said formal support systems, such as individual supervision meetings were not held. However, staff felt able to share ideas and issues and were supported by managers. Managers had oversight of any safeguarding concerns or accidents and incidents. Where actions identified areas of learning we were told these were shared with the staff team. The regional manager said they had identified areas of improvement needed across the service. This included areas of improvement and learning following a recent inquest. A business improvement plan had been drawn up outlining actions required. This had been shared with staff and was regularly reviewed and updated to reflect actions taken.

The programme of staff training, supervision and support needed to be improved, helping to promote and support learning and innovation. It was recognised that communication and clinical oversight of the service needed to be improved. A recent team meeting had been held and changes had been made to the shift handover meetings so information about people and events within the home were effectively communicated to all staff on duty. We found records of handover meetings needed expanding upon to better evidence the discussions held as well as provide sufficient detail to adequately support and inform agency staff. More robust governance systems were needed to help identify themes and patterns and where the service could be enhanced further.