Salthouse Road

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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

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.

Shortly prior to our last assessment, the provider identified a closed culture had developed at the service and took actions to address this. Staff now shared information appropriately and worked in collaboration with other agencies. The management team was keen to improve the service for the benefit of people. They were open and honest through the assessment. The registered manager understood the duty of candour and the importance of acknowledging mistakes made.

Systems and processes did not always address areas which could affect the quality and safety of the service. This had led to breaches of legal regulation. However, the service had inclusive leaders who understood the context in which they delivered care and support and embodied the culture and values of their workforce and organisation.

The registered manager was quite new in post and was developing their knowledge and understanding of regulation. They were visible within the service and modelled the values for the staff. Staff felt confident in approaching them for support or advice, as did relatives and people who used the service. One person said, "I like [registered manager]. They are very comfortable talking with me."

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

A whistleblowing policy was in place. Staff felt confident in raising any concerns about poor practice and felt these would be addressed.

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. Policies and procedures were in place to support the workforce. Staff had access to support through both formal and informal supervisions. The registered manager had held a multi-cultural day for the staff team, to eat food together and play games. This had the aim of promoting cohesion and development of their knowledge and understanding of other cultures.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

The provider’s quality assurance systems did not identify the concerns we identified at this assessment and were not used to drive improvement. Areas for improvement identified at our last assessment had not been acted upon.

The provider and registered manager had begun to make changes during our assessment including seeking professional guidance. They had also made changes to the environment, for example fitting window restrictors and replacing some woodwork.

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. Information was provided about significant events for people. The registered manager attended meetings to share information and gain support.

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 checks completed were not always able to identify areas for improvement. This meant there were missed opportunities to address shortfalls in the safety of the service. There was little evidence of reflective practice and service improvement. For example, the provider did not always ensure incidents and accidents were thoroughly reviewed to help identify themes, triggers or trends that would require further action to be taken. Provider checks highlighted weights were not being monitored effectively, and there was poor recording of fluid intake. This had not been addressed at the time of our assessment.

The registered manager knew how to obtain advice and information to help in the running of the service. They recognised that considerable improvements were needed and responded positively to feedback given.