Abbeydale - Derby

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 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 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 provider had recently introduced digital care planning systems and leaders at the service told us they were working towards developing these systems and embedding them. They described other improvements such as improvements to the staff room and other planned changes including changes to the laundry, nurses’ office and outside space, including further developing access to the outdoor areas of the home. Staff we spoke with were clear they wanted to support people in kind and caring ways.

Leaders at the service worked to deliver care, treatment and support with openness and honesty. However, the skills, knowledge and experience to lead effectively had not yet been fully embedded.

Some aspects of leadership at the service were not yet fully effective as the tools to analyse and review care quality through effective governance were not yet in place. For example, leaders explained some audits were still being designed and developed to meet the needs of the service. Staff confirmed the systems in place were not yet fully embedded and they were still getting used to using them. For example, one staff member told us, “Everyone is working differently and it is new to us still.”

However, staff told us they had good leaders at the service and felt supported. One leader told us, “We have an open door culture, staff know whatever they need they can come to me.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were knowledgeable on how to raise any concerns by using ‘whistle-blowing’ procedures. Whistleblowing is a law that protects staff from being treated unfairly by their employer if they have raised genuine concerns about a person’s care. Staff we spoke with all felt comfortable to approach leaders in the service with any concerns.

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 treated fairly and enjoyed where they worked. One staff member told us they appreciated the caring culture and felt this was one of the reasons they remained working at Abbeydale – Derby.

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.

There were shortfalls in the providers systems and processes so that these were not yet fully effective at identifying and improving areas of the service. For example, we found shortfalls in people’s care plans, risk assessments and other records of care where these contained contradictory information, had omitted details or were not complete.

Systems to improve the service when shortfalls had been identified were not always implemented effectively. For example, leaders had identified actions for staff to take, should the temperature range for the medicine’s fridge be found to be outside of the recommended temperature range. However, we found these instructions were still not being consistently followed by staff and this had not been identified by leaders. Similarly, despite leaders taking action to improve records of the food levels provided when people required food of a specific texture, we continued to find some variations food levels offered and this had therefore not yet been fully embedded.

Systems to review accidents and incidents were not always effective at identifying and mitigating risks. For example, we found incidents of bruising had not been investigated at the time of occurrence. Another skin tear had not been investigated at the time of occurrence and a further skin tear then occurred. Where falls had occurred in communal areas where staff were deployed, there had been no analysis of where staff were positioned at the time of the fall to understand why they were not able to help prevent the fall. This meant systems had not been operated effectively to effectively review, assess and mitigate risks.

Records were not always accurate or complete. Care plans and risk assessments were not always in place for relevant aspects of people’s care. Records of people’s care did not always reflect what staff told us had happened. Care plans and risk assessments contained contradictory information and did not always reflect people’s needs accurately.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

People’s care plans and care records showed the service worked well in partnership with other health and social care professionals to help ensure people receive the care they needed. Links had been established with the local GP surgery and staff worked to support regular home visits to people from the advanced nurse practitioner and the GP. Activities staff worked with local and community organisations to provide activities and events for people. For example, staff had established links with a local children’s nursery as well as organisations visiting the home to provide external activities.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. However, the systems to support this were not yet fully effective or embedded.

Whilst leaders were working to make improvements in the service, these had not always been effective or fully embedded. Incidents and accidents were not yet consistently and robustly investigated at the time of occurrence to demonstrate all necessary actions had been taken to help identify learning and aid improvement in the service.