Nichols 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. This is the first assessment for this service. This key question has been rated 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. The provider had not ensured their systems were always effective in ensuring care was safe and restrictions were managed in line with legal requirements.
 

This service scored 61 (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. The service had a positive and caring culture. Relatives described feeling reassured by the service. One relative said, “I feel I can relax a bit; I know [my relative’s] safe and happy.” Staff also spoke positively about the culture and people they supported. People were supported to be part of their community and to develop and maintain daily living skills, which promoted independence and meaningful inclusion in everyday life.

We identified breaches of regulations at this inspection. This indicated leaders had not always ensured effective oversight of the service. However, we also found leaders were visible and approachable. Staff told us they felt supported and able to raise concerns, and relatives spoke positively about leadership. One relative said, “[Registered Manager] is a seasoned professional. I can talk to her.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt able to raise concerns. A staff member said, “We can raise concerns to the management team.” Relatives also told us they would feel confident raising issues if needed.

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. We did not identify concerns in this area. Staff described a positive and supportive working environment.

The provider did not always have good governance. Concerns were identified during the inspection relating to medicines management, environmental risks, care planning and restrictive practices. This meant risks to people were not always recognised or managed in a timely way, and people’s rights were not always protected. However, leaders responded to concerns when raised during the inspection and told us about actions they would take. We will check for sustained improvement at our next inspection.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. There was evidence the provider worked with external professionals, people and their relatives and supported people to engage in their local community.

The provider did not always demonstrate an effective learning culture, as risks were not identified through internal audits and quality systems. However, once concerns were identified, leaders took action to address them and outlined improvements.