Gordon Lodge Rest 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

We continued to find significant shortfalls in the oversight of the service. There had been no improvement in the systems to monitor the quality of the service and to learn, innovate and improve. Staff told us, the culture within the service since the last assessment had deteriorated and staff had left. The provider had not acted to support and lead staff to be involved in making improvements to the service.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Agency staff told us they had not been supported to understand their role when they began working at the service. They told us they felt they were “thrown in at the deep end”. They had supported people to get up, washed and dressed on their own without being told what people could do for themselves or how they preferred things to be done. They had not been introduced to people before they provided their care. They had not been told about fire safety on arrival and were shown a fire exit later on in their shift. The provider told us there was no formal system in operation to induct agency staff. They said, “The senior would give the relevant care plan information for residents and explain the fire procedure but this was not evidenced”. We asked the provider what action they had taken following our last assessment to ensure staff knew what was required to improve the service and how this would be achieved. They told us they had not met with staff to discuss the shortfalls or shared their strategy for improvement. One staff member told us, “The provider is trying to make changes. Some changes have been made and this has made me feel on edge at times. They are panicking and this puts me on edge. There is not a plan in place to make the changes that I have been made aware of and it’s been more of a panic”. Staff described the leadership as “disorganised” and “chaotic” and gave examples of this. At our last assessment, staff had used a ‘bath book’ to record when people had or needed a bath or shower, this had now been stopped, as this was not person centred care. Staff told us no process had been put in place to replace this and ensure people were regularly offered a bath or shower. There was a risk people would not receive appropriate personal care.

A process was not in operation to ensure agency staff felt supported and understood their role and the care people required. The provider told us they would put a process in place following our assessment. The provider was not achieving their mission to: ‘Provide high-quality, compassionate care that enhances the quality of life for our residents. We strive to create a safe, supportive, and homelike environment where every individual is treated with respect and dignity. Through personalised care plans and committed professionalism, we aim to foster independence and well-being, ensuring an exceptional standard of living for those we serve’. There was no plan in place to achieve this.

Staff told us the service continued to be led by the deputy manager. The deputy manager was working their notice and staff were concerned about how the service would be led when they left. One staff member said, “[Deputy manager] is very supportive and I will miss this, they are worth their weight in gold”. Staff also told us the registered manager was on site more often but this was not at regular times or days, they did not know when they would arrive or how long they would stay. Staff were not clear about their roles and responsibilities. One staff member told us, “There are blurred lines around responsibilities. For example, the deputy manager covered for the head of care when they were off but the head of care did not cover for the deputy manager”. The provider told us the August 2024 medicines audit had not been completed because the deputy manager was on leave. They had not considered completing it themselves or delegating the task to someone else. Senior carers were not aware of tasks we were told they were responsible for, such as reviewing the ‘bowel book’. When staff were not at the service their role would not be completed, there was a risk people would not receive the care they required or items such as medicines would not be ordered. Staff told us they did not feel supported by the provider. Staff’s comments included, “The provider will not except responsibility. They will throw us under the bus” and “There is no clear leadership, the ball game changes every day”. We asked the provider what action they had taken to support staff during changes at the service. They told us, ‘We have spoken to small groups of staff to let them all know about the warning notices received and the required improvements. We have not evidenced this’. These meetings had not been effective and staff were unclear about what changes were being made and why.

Effective systems were not in operation to ensure staff understood their responsibilities and had the skills and competence to complete them. We asked the provider to share records with us to demonstrate how staff were allocated responsibilities on each shift. They did not provide these. We reviewed job descriptions for the manager, head of care and senior carer roles. A job description for the carer role was not given to us by the provider. The job description for the senior carer did not clearly detail their responsibilities over and above those of a carer. They were required to ‘oversee and monitor care workers’ and ‘Take the lead for each respective shift’ but what these responsibilities entailed was not included. For example, inducting new agency staff was not detailed on their job description.

Staff told us they had not been told about any plans to change or innovate the service. They had not been asked to be involved in planning any changes or asked for their ideas. Staff described some of their improvement ideas with us and these reflected the improvements we found were required.

The provider had not been open and honest with people, their relatives and staff about the breaches of regulation and improvements required following our last assessment. No feedback had been shared about the actions required to improve the service. The provider’s Recruitment Retention and Deployment of Staff Strategies stated: ‘We gather feedback from residents and their families to assess if their needs are being met adequately by the current staffing levels and skills. This feedback is essential for adjusting workforce planning’. Relatives had been asked if staff were trained and skilled but not if there were enough staff deployed to meet peoples’ needs. Eight relatives had completed the provider’s feedback survey. The responses had not been analysed to identify any concerns or areas for improvements. Relatives suggested improvements including, opportunities for people to get outside and get involved in some gardening, a monthly newsletter, answering and returning telephone calls, and checking what people need and informing relatives. People and their relatives had not been informed of the action the provider had taken based on their feedback. People had not been given the opportunity to share their views of the service. The provider did not have any systems in operation to ask people for their views and use these to develop and improve the service. This was despite identifying they needed to, ‘Establish and refine feedback mechanisms for residents and families to express concerns and suggestions, using this information to inform continuous improvement efforts’.

Staff told us, the provider had not been as supportive since our last assessment and staffing levels had reduced. Staff told us this had affected their work/life balance, which had deteriorated as they were needing to cover more and more shifts.

There were no policies to support equality and inclusivity.

The provider told us they had increased their oversight of the service. Unfortunately action they had taken had not increased standards at the service to the required levels.

The provider’s business plan stated, ‘Regular audits … ensure that care standards consistently meet or exceed regulatory requirements’. We found there was no effective system to assess and understand the quality of all areas of the service. Medicines audits were not effective and shortfalls we found had not been identified. The area of the medicines audit had not been completed in June 2024. In July 2024 the audit showed oral medicines and creams were not stored separately. No action had been set to address this and the issue continued at the time of our assessment. The audits noted guidance was in place for ‘when required’ medicines. This was not the case and we found no guidance in people’s medication records. The provider’s infection control audit had not driven improvements in hygiene standards at the service. Audits had not been completed in line with the provider's policy and dates for actions to be completed had not been set. Risks to people’s health continued.

Staff had not always worked with other health professionals to make people received the care and medicine they required.

Staff told us, they worked well with other health professionals. They described how they referred people when their needs changed and followed the guidance provided.

We received information of concern from the local council who had identified the level of falls with injuries at the service was higher than other services in the area.

There was no evidence the provider kept up to date with changes in health and social care. They were not part of local forums or received information from groups such as Skills for Care to understand the current requirements and indicators of quality care.

We asked staff what had changed since our last assessment, their comments included, “Stress levels have gone up”, “Medicines monitoring has increased," “Clinical waste is emptied more often” and “The domestics are trying harder”. Staff gave us a number of example’s of how the service could be improved, including, “more staff”, “care plans folders need sorting” and “Roles are carer/domestic, they should be one or the other, there shouldn’t be carers coming off the floor to do domestic work”.

The provider did not have effective processes in operation to improve the quality of the service and people continued to received poor care in an unsafe environment. The provider sent us their business plan dated August 2024. This was aspirational and did not include detailed information about what improvements were to be made or timescales for their achievement. The business plan stated, ‘Gordon Lodge situates itself as a beacon of quality care in the Thanet district of East Kent’. The provider had not achieved this goal and the quality of the service had deteriorated since our May 2024 assessment. One of the provider’s core values was: ‘Excellence: Our commitment is to maintain the highest standards of care through continuous improvement and innovation in our services and facilities’. They were not achieving this aim and did not have a continuous improvement and innovation plan in operation. Another of the core values was: ‘Safety: We are dedicated to providing a secure and safe environment for our residents, staff, and visitors, implementing robust safety measures and emergency protocols’. Again this had not been achieved and robust measures were not in operation to keep people safe and protect them from harm, including the risk of infection.