Archived: Inglewood Residential Home

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 requires improvement. At this assessment the rating has remained 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 57 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights. They did not always understand the challenges and the needs of people and their communities. The provider told us they did not have a documented strategy or vision for the service, there primary goal was to improve the rating and increase admissions to sustain the business whilst improving service quality. The provider told us they were committed to dignity, safety and people’s independence. However, where required improvements had been identified by commissioners there was limited action taken to address the areas of improvement. We found limited progress had been taken to address concerns and there was no timeline for when improvements would be completed. Despite this the staff culture at the home ensured people were treated in a caring and person-centred way and staff worked to support each other as a team. Following the inspection the provider told us there was now a compliance log in place with a timeline to help track all ongoing improvements.

Not all leaders understood the context in which care, treatment and support are delivered. Leaders did not always have the skills, knowledge and experience to lead effectively. The provider had not always ensured care was delivered in line with best practice and legal requirements. Providers must notify the CQC of all incidents that affect the health, safety and welfare of people who use services. The registered manager was unaware of their responsibilities in reporting some incidents to the CQC. This meant there was a lack of knowledge and understanding around the registered managers responsibilities. The provider had not ensured systems in place to manage the service were effective in identifying areas of improvement and ensuring the delivering of safe care and treatment. This meant there were gaps in the service people received.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People and their relatives felt able to raise any concerns about the service if they needed to.A relative told us, “If I had any concerns, I would talk to the registered manager. I speak to them from time to time, or I would talk to the team leaders. They are very experienced and very helpful and bring a stability to the home.” Staff also felt able to raise concerns and could describe the action they would take if they felt the provider did not respond to concerns to ensure people were safe, including raising concerns with other agencies. The provider had a policy in place to support staff policy in place which supported staff to raise concerns, have freedom to speak up and whistle blow. The policy gave guidance to staff on how to raise concerns and assurances these would be taken seriously and investigated appropriately.

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 felt the provider worked to support staff in their employment and took account of any individual needs of staff. The provider had a policy in place to support equality and diversity. The policy set out to ensure all staff worked in an environment which was free from harassment and discrimination. The policy set out how staff would receive equal treatment regardless of their protected characteristics in all aspects of their employment.

The provider did not have effective oversight systems in place to provide good governance. There were some audit systems in place to check on the quality of the service, however these were not always effective in identifying areas for improvement and driving change. A medicines audit was carried out but it had not found the concerns we identified with medicines administration. This meant the process was not ensuring people received safe care and treatment. A resident of the day audit was in place; however, this had not identified the missing information in peoples care plans. Other audit systems were in place to check the safety of the building however we found concerns with the environment and fire safety checks which had not been completed. This meant there was a lack of oversight of the service.

The provider did not respond in a timely way to learning shared by partners to make improvements to the service. Partners told us the provider worked openly with commissioners. A recent quality audit carried out by commissioners identified improvements were needed. However, many of the concerns we found on the inspection site visit had been identified in this audit 8 weeks earlier, but no action had not been taken. This meant we could not be assured the provider was working in partnership with commissioners to make continuous improvements to the service.

The provider’s systems did not always focus on continuous learning and improvement. The provider had no systems in place to identify learning and share this with staff to make improvements. There was no analysis of incidents and accidents which meant learning was not shared with staff to prevent future incidents. There was no learning process in place for safeguarding incidents or complaints and therefore there were missed opportunities to learn and make improvement to the overall quality and safety of the service.