Archived: Sitara Haven

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 regulation in relation to good governance at the service.

This service scored 43 (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 using the service and their communities. The culture in the home reflected that people were not always placed at the forefront of their care with the staff team dedicated to promoting people’s rights, welfare and wellbeing. People were not always involved in decisions and there were no best interest processes or evidence of consent for people who lacked the mental capacity to make certain decisions.

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. The provider was not able to demonstrate consistent knowledge of their legal responsibilities or providing a safe and good quality service.

The service has been rated requires improvement at the last 6 inspections, and no improvement have been made by the leaders to improve the quality of the service

People did not always feel they could speak up and that their voice would be heard. While staff meetings were carried out , we saw little evidence of support or training availible for staff around the freedom to speak up . There was also little informaiton about what staff could do and how to speak up if they had concerns about the quality of care or about the whay the servcie was provided to pople.

The provider did not always value diversity in their workforce. There was little evidence to show that the provider worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider was also not able to demonstrate how they implemented equality, diversity and inclusion initiatives in practice.

The provider did not have clear responsibilities, roles, systems of accountability and good governance.

Governance systems and processes failed to identify, monitor and drive improvement in the quality and safety of services provided, including the quality of the experience for people using the service. These systems also failed to mitigate any risks relating to health, safety and welfare of the people using the service. Some of the issues related to food safety and infection control and prevention had not been picked up by governance processes and no action had been taken to address these issues. The providers checks had not identified that the environment was not being maintained appropriately and decorated according to people’s needs and preferences.

The quality assurance systems and processes were also ineffective because there was a failure to identify and address areas requiring improvement. This placed people at continued risk of avoidable harm.

The provider’s systems to ensure the service complied with the principles of the Mental Capacity Act 2005 were lacking as there was little evidence people’s consent to care was sought or that best interests processes were followed.

The service was not sustainable because the provider had failed to make improvement to the quality and safety of the service despite similar issues having been identified and reported on, at previous inspections. The provider sent action plans following these inspections, but the actions had not been fully implemented to make the necessary improvements in the home.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. The processes in place to provide a good learning culture were not effective.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

We saw evidence external health care professionals were involved in people’s care. For example, GP’s and district nurses.

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 of and quality of life for people. They did not actively contribute to safe, effective practice and research. There were no effective processes in place to identify and share learning across the service in respect of accident and incidents, best practice , and required improvements.

While staff meetings took place, the minutes showed little discussions around the areas for improvements that we identified, for example maintaining cleanliness in the home. The provider was not proactive in ensuring evidence based practice was embedded in service delivery. The providers oversight was ineffective and failed to identify shortfalls we found at this assessment . The service has a history of repeated non compliance despite the providers assurance on multiple occasions that they would improve the quality of the service. The service has been rated requires improvement at the last 6 inspections and this demonstrates a failure to improve the quality of the service and to learn from previous shortfalls.