Pinkneys Road Also known as 87 Pinkneys Road

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Although there had been concerns previously regarding the culture at the service, the registered manager and staff team had worked hard for this to be improved to best support people that lived at the service. The management team was visible in the service, approachable and took a genuine interest in what people, staff, relatives and professionals had to say.

The management team worked hard to instil a culture of care in which staff were valued and promoted people’s individuality, protected their rights and enabled them to thrive. The registered manager set a culture that valued reflection, learning and improvement. Staff knew people well and spoke knowledgeably about the people they supported.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Although the registered manager has recently left the service, one staff member told us, “Current support from the service optimisation managers and regional support manager have changed my views on the service being well led now…every concern raisedis being actioned and I feel that my views are taken into consideration. There are obviously steps needing to be taken to ensure a stable and effective management team is in place but the current support and systems in place have already began actioning concerns and areas that need improvement.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People told us when they raised a concern, staff listened to them. Relatives told us the registered manager and staff were approachable. One relative said, “I always talk to the staff about any concerns I have and regularly call the home every week to check [person] is okay.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they were fairly treated and had never witnessed discrimination or inequality within the service by the registered manager and the deputy manager. Staff described a diverse team who respected and supported each other.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act within a timely manner on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Audits completed had not identified the concerns we found with safeguarding concerns, appraisal and supervisions. This put people at risk of harm as mitigation had not been implemented.

We were not assured the service had systems of accountability and good governance in place to support people, staff and the service. The registered manager acknowledged our findings and assured us they would take appropriate action and make the necessary improvements.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Feedback from people’s relatives was positive about the care provided.

Staff told us they regularly communicated with health and social care professionals as required to meet people’s needs.

Health and social care professionals were complimentary about the service. One professional said, “The staff communicate well whenever there is a concern with [Person].” The provider had a good working relationship with health and social care partners and social services. They understood their duty to collaborate, share information and work in partnership.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Professionals were consulted individually during reviews or conversations where required to find out if they had any concerns or requests. However, relatives told us they were not involved, but advised there was communication with staff if changes to people’s care was required. A relative stated, “I have not been involved in decisions or risks to [person’s] safety, this has always been dealt with by the staff in the home. However, I always talk to the staff about any concerns… I was told verbally by a member of staff [how] they would make adjustments.” We saw their opinions and requests were taken seriously.