Head Office

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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 assessed all of the quality statements within well-led, and found areas of concern. The rating for well led remains inadequate.

We identified one continued breaches in regulation regarding good oversight and governance systems.

We found systems and processes to ensure effective oversight of the service continued to not be effective or in place. The provider's own audits remained ineffective at assessing, monitoring and improving the quality and safety of the service.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff felt there was a good culture within the organisation. They told us, “The management do a very good job. I think for my side, personally I like this company” and, “They are nice to be honest, no problem at all, especially our director, an experienced lady, good with the staff and very flexible.” A staff member said, “They are very responsive. If we send an email they respond to us.”

However, quality frameworks did not always recognise best practice and were not effective in identifying short falls in the care people received or gaps in people’s care records. We found leaders of the service did not demonstrate the required experience or capability to deliver person centred care or to ensure risks were well managed. They failed to recognise they had developed a culture that did not always robustly promote or uphold people’s rights.

Staff were not supporting people to develop, retain their ability to make choices or learn daily life skills routinely. This could result in people's independence not being consistently promoted.

The registered managers told us, “We have a mission statement, but we also reflect on skills and get the teams involved. Our focus has always been that staff are effectively involved, that they have the right tools and support. We have positive behaviour support champions and dignity champions and we want to introduce safeguarding champions. The feedback we have received is that staff feel more supported.” However, information and evidence we reviewed during our assessment did not support the statement staff skills were reflected or that staff were involved. Staff were unable to tell us what the company mission statement was.

Processes were not robust in ensuring staff were supported when people's incidents of distress caused harm or injury to staff.

Whilst some staff told us they felt confident to raise concerns including staff members who told us, “I have provided feedback before, and they (registered managers) did listen to my suggestion, and it was implemented.” Another staff member said, “Once I raised a complaint and my problem was solved immediately, I was satisfied.” Another staff member told us, “ I would be confident to whistle blow, I feel I would be listened to. I have seen leadership being respectful.” However, as we received multiple concerns from staff that stated they could not share their worries with the provider, that sentiment had not been shared by all.

The provider had a survey to gain feedback from people, staff and relatives. When feedback was given the provider sent an acknowledgement email in return. However, there was no system in place to allow people to feedback anonymously or to review any trends or patterns in feedback received. We observed a lot of ‘I don’t know’ answers within the feedback surveys, but we found no actions in place to support people to understand the questions or to change the questions in the future.

The registered manager’s told us, “We make sure we are following guidance (around equality and diversity). We have a mixed workforce and we make sure everything is in place before staff start with us.”

There were policies and procedures in place that staff were expected to follow. All staff had diversity and inclusion training followed by a competency assessment.

The registered managers told us they had made improvements since the last inspection. However, these improvements were not fully evidenced, as we continued to find concerns with the oversight of the service. Staff told us they felt improvements had been made since the last inspection. One staff member told us, "I feel that (the provider) culture has improved dramatically." Another staff member said, "I believe there is a new audit system and this will help." However, when asked not all staff had spot checks completed and staff did not understand what audits were completed and how this improved the service.

Systems and processes were not effective in assessing, monitoring and improving the quality and safety of the service. Audits completed had not identified the concerns we found on assessment, although we identified some areas that had been picked up by the registered managers. For example, one medicine audit had identified medicines errors, we were not assured the appropriate action had been taken to mitigate risk of reoccurrence.

The care plan audits had not identified missing, conflicting or incorrect information.

The care record audit did not identify when people’s food and fluid charts had not been fully completed or monitoring of people’s bowel movements.

In addition, despite staff continuing to give one-person inappropriate foods, this had not been identified by the registered managers.

Despite us raising concerns with the provider in relation to governance, upon review of care note and documentation following our initial start of this assessment, we still found shortfalls.

Systems and processes were not effective in ensuring staff did not work excessive hours, were safely recruited and had received appropriate training for their roles and responsibilities. This put people at risk of harm as staff did not always have the information required to support them safely.

Following our assessment, the registered manager’s told us they planned to introduce a biometric and facial recognition system to the service which would help monitor staff timekeeping and working hours.

People were not always able to access their local communities in line with their wishes, such as some people wishing to attend a day centre, but not always being supported to do so.

Stakeholders told us they were not always consulted in relation to people’s care. One told us people had missed health appointments and staff gave conflicting information on why this was.

The provider worked with external agencies to help support them to make improvements within the service. Some staff attended an engagement and communication workshop organised by the community learning disability team. However, this was not effective in ensuring good care was always being provided as a result.

The registered manager’s told us, “We always make sure we learn from our accidents and incidents and lessons learnt are cascaded to the whole staff team. We share the analysis of any surveys that are carried out and have discussions about this. We are looking at ways to improve and be innovative, such as approaching another provider to run some shared training.”

However, we found concerns with the recording and reporting of accidents and incidents and were not provided with any evidence to show effective learning had occurred in relation to reviewing these incidents.

Systems and processes failed to ensure effective learning from previous incidents or accidents.