High Lea 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 requires improvement. 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 governance at the service and meeting responsibilities in sharing safeguarding information. The home remains in breach of governance.

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.

Poor leadership and governance arrangements meant staff did not have a clear understanding of expectations, priorities or their responsibilities in keeping people safe.

The service had been without a registered manager for a significant period, which negatively affected the culture of the service. There was a lack of clear leadership to set standards, model good practice and promote shared values. The nominated individual, who was acting in a management role, did not demonstrate sufficient knowledge of regulatory requirements, which reduced clarity and direction for staff teams.

Expectations were not clearly communicated or embedded from leaders. This was reflected in variable approaches to risk management, safeguarding, record keeping, medicines management and consent. Staff did not routinely escalate concerns, reflect on incidents or work together to improve practice, which showed a reactive rather than learning‑focused culture.

The provider did not promote a culture of learning and continuous improvement. Concerns, incidents, feedback from people and relatives, and monitoring information were not routinely reviewed or used to improve care. There was no evidence of reflective practice, shared learning or action taken to prevent issues from recurring in the future.

People and relatives did not always feel reassured by the culture of the service. Relatives we spoke with told us about limited communication, unresolved concerns and a lack of transparency. 1 relative told us, “When changes happen, we are not always made aware and likely to find out from staff”. This reflected a culture that did not place people’s experiences, views and safety at the centre of decision‑making.

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, and they did not do so with integrity, openness and honesty.

Leadership arrangements and a lack of regulatory understanding limited the provider’s ability to ensure people received safe, person‑centred and well‑managed care.

The absence of a registered manager resulted in poor oversight, limited accountability and a lack of direction for staff. The nominated individual did not demonstrate sufficient knowledge of regulations or legal responsibilities, which reduced their ability to lead effectively and ensure safe practice.

People and relatives who raised concerns did not always feel listened to and action was not always taken on feedback given to improve experiences. Some people we spoke with gave examples of where they had asked about new activities taking place within the home, but no action was taken. This made them feel not listened to.

Inclusive leadership was not evident. People were not consistently involved in decisions about their care, risks or daily routines, and relatives were not always kept informed or reassured. Leaders did not ensure systems were in place to support shared decision‑making or meaningful involvement, particularly where people had changing needs or required additional support to participate.

Leaders did not foster a learning or improvement‑focused culture. Incidents, safeguarding concerns, feedback and monitoring information were not routinely reviewed to drive improvement. There was limited evidence of reflection, learning or action taken to prevent issues from recurring.

People did not always feel they could speak up and that their voice would be heard. Concerns raised by relatives, such as issues relating to cleanliness and uncertainty around care practices, were not addressed in a timely way. This indicated people did not always feel confident that raising concerns would lead to improvement.

Staff did not demonstrate confidence in escalating concerns or challenging poor practice. Issues relating to safeguarding, medicines management, risk management and environmental safety were not consistently identified or acted upon by the provider internally, suggesting staff were not fully supported or encouraged to raise concerns when things were not right.

Leadership arrangements did not support freedom to speak up. There was no evidence of formal systems or processes to encourage feedback, raise concerns, or learn from mistakes. The provider did have speaking up policies.

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

Leadership and governance arrangements did not provide assurance that inclusive practices were embedded or promoted across the service.

There was limited evidence leaders actively considered equality and inclusion in how staff were supported to deliver care. Inconsistent records such as risk assessments indicated staff were not always guided to provide individualised, inclusive support that respected people’s differing needs, backgrounds and preferences.

Leadership arrangements did not support inclusive working practices. The prolonged absence of a registered manager and limited knowledge of the nominated individual reduced opportunities to promote inclusive values, provide guidance, or model good practice for staff teams.

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 securely with others when appropriate. The provider did not have effective governance, management or sustainability arrangements in place to ensure the safe, consistent and long‑term delivery of high‑quality care. Systems to monitor, manage and improve the service were poor and ineffective, which placed people at continued risk of harm.

Governance systems were not effective. There were no robust processes to review incidents, accidents, safeguarding concerns, medicines practices, or monitoring information such as fluid intake and falls data. Where issues were identified, there was no evidence of analysis, action planning or learning. This meant risks were not escalated, improvements were not made, and poor practice continued unchecked.

Quality assurance processes did not provide assurance. Audits and records were inaccurate or unreliable, and management oversight was inconsistent. Safeguarding notifications had not been submitted as required, and there was no system to ensure statutory reporting duties were consistently met. This reduced internal and external oversight of the service and increased potential risks to people.

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. The service did not demonstrate effective partnership working with healthcare professionals. Changes in people’s health needs, such as repeated falls, low fluid intake and deteriorating physical condition, were not consistently escalated for medical review. Working arrangements with safeguarding partners were not effective. Injuries and safeguarding concerns were not consistently shared with external agencies, and required notifications to CQC had not been submitted. This limited multi‑agency oversight and reduced assurance safeguarding concerns were appropriately managed.

People’s links with the local community were limited. People told us they did not go out with staff and would like more opportunities to access community activities, including attending church. This showed the service did not actively support people to maintain community connections or fully promote social inclusion.

The provider did engage positively with some visiting professionals. Feedback from the optician was positive, indicating cooperation during visits. However, this was not consistently reflected across other professional relationships, particularly where escalation and follow‑up were required. The local authority provided feedback to us which included concerns around the care people were receiving in the home and lack of governance. The local authority raised concerns around responses received from the service.

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. Systems to identify lessons from incidents, monitoring, feedback and day‑to‑day practice were not embedded or consistently applied, which limited opportunities to improve care and outcomes for people.

The service did not routinely learn from incidents or concerns. Accidents, incidents and safeguarding matters were recorded but not reviewed to identify themes, trends or areas for improvement.

Feedback from people and relatives was not used effectively to drive improvement. Concerns raised about cleanliness, activities, food choices and involvement were not addressed in a timely or consistent way. This indicated the provider did not have systems to capture learning from feedback or use it to make meaningful changes to the service.