Country Court

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 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 service was in breach of legal regulation in relation to the governance at the service.

This service scored 57 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider did not always demonstrate a clear and consistent vision for the service. Whilst staff and people were consulted and their views analysed, staff reported feeling uncertain about the future of the service and expressed concerns about underinvestment, lack of direction and leadership from the provider. Visiting professionals also noted the absence of a clear strategic direction from the provider and concern about the lack of a registered manager. However, the acting manager was commended by staff and visiting professionals for their dedication in “stepping up” to the role and undertaking this longer than expected due to the provider’s lack of active pursual of recruiting a registered manager.

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.

Leadership was not effective in ensuring compliance or driving improvement. The provider was described by staff and professionals as lacking understanding of the social care sector, which had hampered progress and directly undermined the progress and improvements put in place by the external consultant. There was no registered manager in post, and attempts to recruit had been slow. Staff valued the acting manager and deputy, describing them as supportive and committed, but staff felt undermined by the provider’s decisions. The provider was not consistently responsive to urgent requests from the service, and governance systems did not ensure timely action on identified risks. For example, on some occasions, food deliveries were cancelled as the provider did not ensure there were enough money available for kitchen staff to order food. Despite this. people did not go without food and the provider had given assurances this would not happen again in the future.

The acting manager had fostered a positive culture where people felt they could speak up, and their voice would be heard.

Staff told us they felt able to raise concerns and were confident these would be addressed by local managers, but not by the provider. People living at the service also reported they could speak up if they had worries. Complaints were responded to appropriately, and staff described the acting manager and deputy as approachable and supportive.

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 reported feeling supported by the acting manager and deputy and described the team as inclusive and cooperative. There was no evidence of discrimination, and staff spoke positively about teamwork and morale despite concerns about the service’s future. However, there were no clear examples of proactive initiatives to promote inclusivity and celebrate diversity from the provider.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems were in place but were not consistently effective. Audits introduced covered all areas of the service, but audits did not always identify issues found during inspection, such as medication recording errors and out-of-date care plan reviews. Provider oversight failed to ensure timely action on escalated concerns, and some environmental issues highlighted in audits remained unresolved. The absence of a registered manager for an extended period represents a significant sustainability risk.

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.

The service worked with external professionals and maintained links with the local authority and safeguarding teams, although relationships were strained due to previous concerns. People and relatives spoke positively about staff and care, and staff sought feedback from people about meals and daily routines.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider did not always demonstrate a consistent and proactive approach to learning and improvement. Whilst some systems were in place to review incidents and share lessons learned, these were not embedded across the service. In some cases, concerns highlighted through audits were escalated to the nominated individual but were not acted upon promptly, limiting the impact of these processes. Overall, whilst there were pockets of good practice, the lack of a robust and responsive improvement framework meant the service did not consistently improve in all areas. Due to improvements implemented by the external consultant being reversed by the provider, coupled with the lack of an experienced registered manager to set and drive expected standards, further impacted the potential improvements which could have been made.