Ailwyn Hall

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

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 provider was in breach of legal regulation in relation to good governance as the quality assurance tools was not embedded and overall governance at the service was not effective.

This service scored 46 (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 an inclusive and person-centred culture. The service had the beginning of an extension being built and when we spoke to the registered manager, they were not sure what was being built, the timescale or the plans for it. There were no business plans about this. The service had an improvement plan in place. This was not being routinely reviewed and updated. Improvements had not always been made and had not been embedded.

The provider did not ensure the service had capable and inclusive leaders. The registered manager and deputy were undertaking their level 5 in health and social care and were supporting each other to achieve these. We found a gap in the registered manager’s knowledge on notifiable incidents they had reviewed their statement of purpose but had not submitted this to the Care Quality Commission. They had not raised safeguarding referrals when unsafe admissions posed a risk to people. Staff were inexperienced and relied heavily on the manager and deputy while supporting people with high dependency care and support needs. The registered manager was not aware of the importance of following duty of candour appropriately and was not following the services policy or procedure around this, speaking to the registered manager about this they said they still informed families, but they did this verbally as they felt it was informal and did not think of implications of having no written evidence to show how they applied duty of candour.

Most of the staff we spoke felt they we able to raise concerns and knew they would be addressed by management. We reviewed the services and procedure around this, and it was a clear process for staff to follow.

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. The service supported staff with flexible working arrangements and the staff we spoke with said where needed additional support was given.

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 governance, management and sustainability were poor within the service. Audits were not robust and did not always identify areas of improvement and when shortfalls were identified, these were not reassessed, and this resulted in audits with actions either not being recorded or where actions were recorded, they were not completed. We noted actions from staff meetings were not being followed through, monitored or reviewed. The services statement of purpose was inaccurate. Changes and improvements had not always been embedded within the service; for example, the competency checklist, was a process being implemented within the setting to assess staff's knowledge, however only a small number of staff had been assessed and a gap in staffs' knowledge had failed to have been identified. These included a lack of accessible toilets, security concerns, poor medicines management and failing to protect people from risk of harm. Processes were not being reviewed appropriately. For example, a dependency tool used to calculate staffing levels was not accurate, and policies were not being followed appropriately.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information with partners for improvement. One healthcare professional we spoke with said “I don’t always feel that the service is proactive in passing on information, unless I instigate these discussions” The management team had failed to inform partners in a multi-disciplinary team meeting which involved a medication review of several people at the service who had run out of their medication.

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. While the service was being reactive to learning and implementing improvements, they were not being proactive. The provider did not measure up all suitable options and risks and this impacted on people’s care. The provider placed restrictions on people without assessing these. The provider’s systems for monitoring and identifying risks did not always ensure these were mitigated.