North Bay House

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 Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance of the service and the failure to notify CQC of significant events.

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.

The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. There were widespread failures across the service, and the culture did not promote people’s safety or increase their experience of good care.

The provider’s statement of purpose set out the aims and objectives for the service to ensure people had positive experiences and received high quality care. However, the provider and leadership team failed to ensure these standards were implemented. There was a lack of oversight to ensure people were supported appropriately and engaged in a way that was meaningful to them.

Following the inspection the registered manager left their post. They lacked knowledge in multiple areas, including how to prioritise safe, high-quality, compassionate care, resulting in poor outcomes for people.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively. There had been a failure by the management team to identify and act where care and support could be improved, or practice challenged. Quality assurance processes were limited and not robustly implemented. The provider had not had oversight of the service to ensure the management team were providing safe, high quality care, as they did not undertake audits to identify potential shortfalls.

People did not always feel they could speak up and that their voice would be heard.We received mixed feedback from staff about speaking up and sharing their views. Most staff said they felt able to raise concerns and they felt they would be listened to. However, prior to, and following the inspection, we received feedback from anonymous staff members that they had concerns about the service but had not felt empowered enough to speak up for fear of retribution. This indicated that systems currently in place were not effective for some staff.

People mostly felt able to speak up, though not all felt their concerns would be acted on.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Some staff had experienced physical or verbal abuse by people who may be experiencing periods of distress or agitation. There was no evidence that any de-briefs took place to ensure staff were supported and felt safe. Some staff had contacted CQC anonymously to share their concerns about working at the service. Only 3 staff had completed equality and diversity training. Equality and diversity training is essential to create a safe, respectful, and inclusive environment for people and staff, ensuring that everyone receives the care and support they deserve.

There was evidence of staff meetings and supervisions to show staff were included in decision making. One staff member described how the provider had supported them to work flexibly whilst experiencing personal difficulties which they really appreciated.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this with others when appropriate. For example, the governance systems in place had failed to ensure a consistently good service was delivered and had not identified the widespread shortfalls identified at this inspection. Risk management was poor and there was a lack of analysis to establish the cause and if any lessons could be learnt and shared with staff to prevent a recurrence.

The provider and registered manager did not always identify and mitigate risks to people’s safety. Documentation was not always accurate or complete. Areas of the environment were not safe and placed people at risk of harm. The provider and registered manager were not clear about their regulatory responsibilities to report significant events to CQC, and this meant we were not aware of incidents which had taken place in the service, and which may have prompted an earlier inspection. There was a lack of oversight, accountability and governance.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Care plans and risk assessments did not reflect people’s current needs. Therefore, it was unclear how accurate information was being shared with other health professionals involved in people’s care. People and their relatives told us they were confident the service would contact healthcare professionals when required. However, during our inspection we found people’s specific needs were not always known or understood by staff and there was insufficient monitoring of people’s health. Therefore, the provider did not have the information required to help them ensure appropriate referrals would be made and information shared in a timely way where needed.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. There was no evidence that lessons had been learned from accidents, incidents, or falls, due to the absence of meaningful action to review and analyse these events for trends, patterns, or opportunities for improvement.

Quality assurance systems were ineffective, which limited the provider's ability to drive improvements that promoted equity and positive outcomes for people.