63 Coronation Road

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 good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent and not always effective to monitor the quality and safety of the service. The service was in breach of legal regulation in relation to good governance.

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. The provider’s vision, mission, and values were clearly outlined in the statement of purpose. Staff reflected these aims in their working practice, which we observed. Staff and leaders promoted a positive culture and were committed to providing a quality service to the people they supported. The provider demonstrated respect for people’s human rights and valued diversity within the organisation. Staff spoke positively of the leadership team and their roles within the service. A staff member said, “Staff morale is quite good.” Another said, “We trust each other, which is really important.” A relative said, “[Manager] is helpful, staff are very cheerful.”

Whilst the provider had inclusive leaders who understood the context in which they delivered care, treatment and support, and who embodied the culture and values of the organisation, leaders did not always demonstrate the skills, knowledge or experience required to lead effectively. During the assessment, the provider did not demonstrate sufficient knowledge of incidents or events requiring notification to the CQC. This was raised with the provider, who confirmed learning would be shared with the team to prevent recurrence. Leaders were available throughout the assessment, supported the process, and responded appropriately to feedback. Where shortfalls were identified, they acted promptly and developed an action plan. At the time of the assessment, no registered manager was in post; however, by the end of the assessment, we were informed a new registered manager had been appointed. Staff spoke positively about the management team and reported feeling supported. A staff member said, “We can call to the managers if we need anything.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Although some processes intended to support staff in speaking up, such as supervision and appraisals, were not always completed, staff told us they felt able to approach the management team and share any concerns. A staff member said, “I do, I feel supported by the team here.”

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’s policies and procedures promoted equality, diversity, and human rights. Staff had completed equality training to improve their understanding of protected characteristics and awareness of bullying and harassment. Staff told us the management team was supportive, inclusive, and fair to all staff. Staff shared examples showing the provider had been flexible and supportive in response to staff’s personal circumstances and religious beliefs.

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. The provider was conducting a series of service level and provider level audits to monitor the quality and safety of the service. However, these audits were not always effective in identifying gaps in processes and where improvements were needed. For example, audits had not addressed issues we identified with the premises, support plans, staff support and CQC notifications. The provider’s audits had identified some areas for improvement; for example, in relation to infection control and MCA however timely action had not been taken to address the shortfalls. Some service level audits were not kept up to date during a recent period when the service did not have a registered manager in post. The provider responded positively during the assessment by developing an action plan and providing an update on actions taken to address shortfalls.

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 provider worked effectively with other professionals and maintained positive working relationships. The service operated in partnership with professionals, including the GP, occupational therapists and local mental health teams. Professionals told us they experienced positive working relationships and clear communication with the service. Managers told us there were opportunities to connect and learn from colleagues across the organisation, for example by attending a managers’ safeguarding conference and peer support groups.

The provider had not always focused on continuous learning, innovation and improvement in the service. Whilst there was some evidence of learning being shared with the staff team, processes intended to support further discussion and learning with staff were not being consistently completed, for example staff supervisions and appraisals. Provider audits and checks had identified some of the shortfalls identified during our assessment; however, timely action was not taken to improve these areas. Further work was needed to establish a consistent culture of learning, innovation and continuous improvement. The provider showed an understanding of how to improve the service and had responded promptly to the shortfalls identified by developing and implementing an action plan. Staff reported positive communication with managers and told us they felt able to report any concerns as well as make suggestions for improvements.