Pear Tree Residential Care 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 inadequate. At this assessment the rating has remained 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 the legal regulations in relation to fit and proper persons working at the service and governance at the service.

This service scored 32 (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.

The vision and values of the service were not embedded or understood by the management team. There was no culture of listening or a desire to drive improvement. The service was being supported by the local authority quality improvement team but the provider had failed to take action and address concerns raised.

The provider had not done enough to identify the potential risk of a closed culture within the service due to inherent risk factors. This meant people using the service may have been at risk of harm because elements of a closed culture were present.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The registered manager did not demonstrate an understanding of their responsibilities in providing safe and effective care. The registered manager did not take action to address concerns we identified in how risks to people were being managed at previous assessments. They did not respond appropriately to prevent the recurrence of adverse events, including falls, and they had not acted when alerted to poor practices regarding fire safety. Systems and processes were not operated effectively to ensure the service was assessed or monitored for quality and safety in line with requirements. This led to multiple repeated breaches of regulation.

People did not always feel they could speak up and that their voice would be heard.

The provider did not provide regular opportunities for people to provide feedback about the running of the service. Some staff did not feel they could approach the management team with issues as they were not confident these would be responded to appropriately. One staff member told us, “You can't say anything to help as they don't take it well.”

The policy in place around whistleblowing did not provide staff with sufficient guidance on how to raise concerns externally if they felt their concerns were not being addressed.

Information from records and from relatives did not demonstrate that the provider was notifying families of incidents in line with duty of candour requirements.

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

Staff did not have regular opportunities to provide feedback about the service. Staff meetings were not always utilised as an opportunity for staff to feedback about their ideas or concerns at the service.

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.

At our last assessment the provider failed to ensure there were effective governance systems to assess, monitor and drive improvement in the quality and safety of the service. At this assessment we found little improvements had been made and people continued to reside in a service where widespread and significant shortfalls remained.

Issues relating to audits, essential safety checks of the environment and equipment, including fire safety issues had not been addressed.

Policies were either not in place or were not sufficiently robust to guide safe and consistent practice. This meant leaders did not have the systems they needed to oversee the quality and safety of the service, and staff lacked clear direction to support good practice. As a result, the provider could not assure themselves care was being delivered in line with regulatory requirements or best practice, and we saw how risks were not consistently identified, monitored or addressed.

Records failed to identify the care people required or received. Care plans did not contain detailed information regarding people's health needs. Important information about incidents and risk to people’s safety was not always recorded within appropriate records and monitoring charts were inconsistently completed. For example, there were large gaps in recording for people's catheter output despite this being raised at the previous assessment.

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.

External professionals and agencies had ongoing involvement in people's care. The service had a good relationship with the local GP and district nurses. The local authority had provided supportive interventions to try and drive improvements, however these had not had the desired outcomes around compliance.

The provider did not focus on continuous learning, innovation and improvement. 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.

There remained little evidence of learning and service improvement during this assessment.