St. Michaels Lodge Also known as Shakthi Healthcare Limited

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

Systems to monitor the quality of the service were ineffective. Audits were not being completed which would have give the registered manager to identify the issues found during our site visit. There were concerns with recruitment records, training, risk assessments and daily logs. This was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The registered manager told us they were trying to recruit extra staff and a deputy to support them in their role and quality assurance. Staff told us they were well supported by the registered manager and they could raise concerns freely. Feedback from a health professional was positive when discussing their interactions with the registered manager and staff within the home.

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.

Shared direction and culture -Feedback from staff and leaders Feedback from staff on the culture and direction of the service was positive. Staff felt well supported and confident in the management of the service, direction of the service and support provided to ensure they could meet people's needs and give them the best outcomes they could achieve. The registered manager told us they had experienced a challenging period at the home due to a lack of external support. The registered manager told us this had an impact on any innovative practice, as the staff were working hard to meet people's daily needs.

The systems in place did not support the development of the service to improve. Quality monitoring of recruitment, training, care planning, risk assessments and daily records was not embedded or in some instances taking place at all. This meant the registered manager did not have full oversight of the service and what needed to improve. From the records viewed it appeared there was a culture to rush training as this had not been challenged by the registered manager which in turn did not demonstrate a shared direction to thorough learning. Staff told us they had two weeks to complete their training modules but we had asked to see training and we found a number of courses had been completed by the deadline we had requested.

Staff were complimentary of the registered manager and told us they received good support from them. A member of staff told us they regularly spoke with the registered manager, they said, “I have regular 1:1 meetings with them every week, I can speak openly to them about any topic.”

The registered manager provided people living at the home and staff with opportunities to meet and discuss matters with them. Surveys were conducted for people using the service and their families. The home did not complete a full analysis to support them to make improvements within the home where needed.

Staff told us they enjoyed working at St Michael’s Lodge and felt well supported by the registered manager. A member of staff said,” I am able to speak to [registered manager] about any topic.” Another member of staff said, “I do feel supported and feel I can speak to [registered manager] about anything.” Staff told us they felt confident to approach the registered manager with concerns about the people they were supporting or if they required guidance in their role.

Monthly keyworker sessions with people using the service took place, records confirmed this. Where people did not wish to speak at the time, staff did not force them and advised they would try another time. We reviewed records of minutes of meetings which took place within the home. These were occurring every 2 months. Staff confirmed they attended meetings and found them useful and an opportunity to raise issues and discuss people’s needs within the service. A whistleblowing policy was available but did not provide information on who staff should raise concerns to.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us they knew what was expected of them as they discussed this during team meetings and their 1:1 with the registered manager. Staff told us the management of the home was good. A member of staff said, “Yes, [registered manager] is available at all times. She listens to me, motivates and encourages me. I can approach the [registered manager] at any time and with any need.”

Records were not easily accessible. During our visits staff told us they did not have access to care plans and risk assessments as these were with the registered manager. The registered manager informed us they were in the process of updating records and they were aware this was an area that needed addressing. We had concerns quality assurance records were not contemporaneous, for example an audit dated January 2024 advised all the service users care plans were to be updated on the computer. The next audit in February 2024 advised this action had been completed, however, care plan records were not available on the home’s computer for staff to review. This audit, as completed by the registered manager was not an accurate reflection of what was seen during our visit in March 2024. We found issues with recruitment records for example, old disclosure and barring records, incorrect information about previous experience, incomplete induction checklist and missing references. The registered manager provided an explanation for them once we brought it to their attention, but there was no quality assurance to show this was done at the time of recruiting the staff member. The recruitment files viewed were present to us as complete. Daily logs were not being audited for accuracy and content and the registered manager told us they did not know they had to be audited. We found duplicate comments within daily records which meant we were not assured the care documented was an accurate reflection of care and support provided. As this was not audited the registered manager could not identify the issue and discuss with staff as lessons learnt going forward. The registered manager did not have a deputy at present, they advised they wanted to recruit one into the home to support them with management duties and paperwork. The above was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

Staff told us they would benefit from specific mental health training, in particular staff who did not have any prior experience in the area. Staff told us they worked with each other and could seek guidance and support from experienced staff and the registered manager. Staff and the management worked with health professionals for extra support and guidance to ensure people received the care needed.

The registered manager acknowledged staff without prior knowledge would gain better understanding with specific mental health training but this had not been sourced as yet. The registered manager had prepared a business plan for service improvement, this referred to a number of different audits and learning from incidents. However, the monthly audit in January 2024 made reference to care plans needing to be updated on the computer system. The audit for February 2024 said all actions had been completed, however during our visit in March 2024 the care plans were not available on the computer being completed from. This meant we were not assured of the authenticity of audit records.