Brockenhurst

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• 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 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 legal regulation in relation to governance at the service.

This service scored 36 (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. They did not always understand the challenges and the needs of people and their communities.

There was a failure to demonstrate a positive culture that was focussed on learning and improvement. Systems were not effective in identifying shortfalls and making changes to improve the service. Staff told us, and records included, that the ethos of the service was to provide people with the opportunity to move around the home freely and independently without restrictions. However, there was a failure to understand how risks could be managed. The provider did not accept concerns identified at this inspection regarding failures in risk management. For example, when discussing the risks of falls they said, “Everyone is at risk of falls.” This did not provide assurance of their understanding about how risks could be assessed, resolved, improved or managed.

Staff told us they reported any concerns to the provider who was in day-to-day charge of the service. Staff did not demonstrate an understanding of their role with regard to safeguarding people. Staff did not always know what action they should take or how they should respond if, for example, there was an altercation between two people. This meant safeguarding events had not been consistently investigated and reported to external bodies to ensure openness and transparency.

The language used by staff, including in people’s care records, was not always respectful and did not support people’s dignity. Some people with dementia were observed walking independently throughout the service, in records staff frequently referred to them “wandering”. One daily record included that staff’s view that the person was “Completely impossible today,” and described them as “Very challenging.” This did not support a culture of respect for people’s dignity.

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 provider was in day-to-day charge of the service, they used the title “Matron,” this is usually the title for a senior nurse. This, together with their nursing uniform and badges, gave the impression they were a nurse, although they had not maintained their nursing registration. The title was included on the provider’s documents including care plans. Staff, people and their relatives, were heard referring to the provider as “Matron.” This was not transparent and there was a concern that this gave the wrong impression regarding the professional status of the provider. The provider had decided some people should receive modified diets as they were having difficulty with their food. However, they had not made referrals to SaLT for a professional assessment of their needs. This gave cause for concern that the provider was making decisions about people’s care which were outside the scope of their professional role.

Some people were noted to have slipped to the floor from a chair, including when they tried to stand without assistance. The provider told us they had not considered these incidents as falls and there had been no review of risk assessments or care plans to prevent further occurrences. This did not provide assurance of their understanding of risk management.

The provider lacked understanding of the safeguarding process, they told us they had not realised they should be reporting altercations between people as safeguarding incidents.

Staff told us they referred to the provider for all decisions relating to people’s care needs. One staff member said, “Matron is here all the time, and I can call her if she isn’t.” This did not provide assurance that there were effective management systems in place to support the running of the service when the provider was not there.

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

Most staff spoke highly of the provider and the support they received. However, some staff said they did not feel able to speak freely. One staff member told us, “Nobody listens, there’s no point in saying anything or making suggestions.”

Records of staff meetings showed the provider invited staff to contribute and raise any concerns or suggestions.

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.

The provider had recruited a diverse workforce. Some, but not all staff, had completed training in equality and diversity. One staff member described being supported to progress in their role and described how they had completed training to support them with this goal. Another staff member described how the provider had agreed to flexible working arrangements to support them in their role.

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.

Management systems were not effective in identifying shortfalls in the quality and safety of the service. The provider’s systems had failed to identify multiple concerns identified at this inspection, such as the failure to assess, review and manage risks to people, including risks of falls, risks of choking, and risks associated with people’s health and well-being.

Systems for monitoring the safety of the environment had not identified risks, including the failure to assess and mitigate risks of falls on the stairs. An infection control audit included checks on storage of cleaning products. This had not identified the failure to store cleaning products in line with COSHH requirements. Fire safety checks had not identified a failure to update staff knowledge and skills with regular fire drills.

The provider did not always demonstrate good oversight of the service. Systems for monitoring incidents and accidents were not robust. The provider and deputy manager could not be sure how many people had fallen in the last month, when or why. This meant they were not clear about the level of risk. The provider told us nobody needed support to move with the use of a hoist and sling, however staff told us they were using this equipment to support two people. There were no risk assessments or care plans in place to provide guidance for staff in how to do this safely and in the way the people preferred. We observed a person was not supported to move into a safe position in bed.

Audits of medicine administration were not effective. Errors had not been recorded as incidents or analysed to prevent further incidents. A monthly audit did not provide enough detail to give assurance. For example, it noted a staff member has been checked but does not confirm who or what was checked. The lack of audits of medicine stock meant the provider could not be assured stocks were accurate. Audits had not identified shortfalls including the lack of PRN protocols or lack of systems for administering homely remedies. The provider’s medicines policy included that medicines were stored in a medicines room which was a secure area. However, the medicines room was not locked and we observed people were walking into the room when there were no staff around. Although the cabinets and cupboards within the room were locked this was not a secure area as described within the provider’s policy and there was a risk that people could access medicines if for any reason they were left out of the storage cupboard.

Records were not always accurate, complete and contemporaneous. Some records were handwritten and were difficult to read or illegible. Daily records had gaps where no information was recorded, sometimes for several days. Information was contradictory and did not provide clear evidence of how decisions were made.

Systems to support the management of staff were not robust. There were no records of supervision meetings, this meant the provider could not be assured staff were receiving supervision regularly. Some staff told us they had not received supervision.

Systems to support the deployment of staff were not effective. The provider told us they assessed the personal care needs of people to determine how many staff were required and where they should be deployed across the service. This did not take account of changes in people’s needs, including dementia, mental health or mobility. The provider told us staff were supporting people when using the stairs to reduce risks of falls, however the deployment of staff had not been revised to accommodate this requirement and we observed staff were not always available in the vicinity of people who were using the stairs.

The provider did not 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.

Systems for monitoring incidents were not robust. Altercations between people with dementia were not always reported to the local authority or to CQC in line with safeguarding procedures. This did not support openness and transparency. Before this inspection the local authority raised concerns about the provider’s understanding of the safeguarding process.

The provider had not made referrals to appropriate professionals for people who required SaLT assessments due to difficulties with eating and drinking.

Following the inspection the provider had employed the services of a consultant to support the running of the service and to improve collaborative working.

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 and quality of life for people.

The provider’s systems failed to identify shortfalls and support learning to make improvements. Incident records were not always accurate and complete, there was a lack of analysis to identify patterns and trends and to learn from mistakes. The provider’s ambition for people to have the freedom to move around the service independently was embedded within staff practice. However, there was limited understanding of how to assess and manage risks of falls for people and this was having a detrimental impact on people’s safety. Although risks for some people were apparent, the provider had not acted quickly to ensure risks were minimised. This did not demonstrate that there was learning from incidents.