Archived: Octavia Housing - James Hill House

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. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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.

Requires Improvement – This service generally maximises the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

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 registered manager was visible and involved, ensuring staff knew what was expected and felt supported. Staff described the culture as open and safe, where they could speak up and ask questions. Regular team meetings kept staff coordinated, which helped them work well together.

However, despite this positive culture, medicines management issues indicated that the provider’s values were not always consistently applied in practice. Staff sometimes lacked clarity on medicines protocols, care plans did not fully reflect people’s support needs, and governance systems did not always prevent avoidable risks. There were risks we identified for the provider in delivering their shared direction and culture.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The care team leader felt confident and empowered to make decisions. They said, “I can speak up about my concerns and needs, and I know I will be listened to and supported.” Staff frequently mentioned the registered manager and team leader as helpful, supportive, and encouraging. They felt confident in the leadership’s responses.

The registered manager started working for the provider in a different role and gradually took on more responsibility before becoming the manager. They grew their skills within the organisation and led with hands-on experience. This background helped them understand staff needs and challenges, which improved leadership effectiveness and team confidence.

Staff described the leadership as approachable, compassionate, and involved.

Leaders took time to understand individual staff strengths and used this to build confidence and accountability across the team. For example, staff described how the registered manager encouraged them to take initiative and trusted them to make day-to-day decisions. This helped develop a culture of shared responsibility, where staff felt ownership over the quality of care.

However, we identified that leaders were not fully responding to the issues we identified which were affecting the quality of the service. For example, the medicines management issues demonstrated that, despite strong leadership, guidance and oversight were not consistently embedded in practice. Staff sometimes lacked clarity on medicines protocols, care plans were incomplete, and audits did not always prevent avoidable risks. This shows that while leaders were capable and supportive, further work was needed to ensure that their expectations and values translated into consistently safe and effective practice across all areas.

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

Staff said they felt able to speak openly, report concerns, and raise issues without fear of reprisals. Staff felt that the leadership was available. A care worker said of the leadership, “They are there for us. I feel free to speak up. I can say if I have concerns about anything with the manager and team leaders as well.”

Duty of candour was practiced, showing transparency with families and professionals.

A newly recruited staff member said their team leader checked in weekly and held supervisions at 3 and 6 months, giving clear chances to share feedback and raise any issues. The care team leader emphasised open communication, stating that staff were encouraged to raise concerns. The provider created a safe environment for people to voice ideas and challenges.

People being supported said they felt listened to and said they were comfortable expressing their needs.

The provider valued diversity in their workforce and worked towards an inclusive and fair culture by improving equality and equity for the people who worked for them. Staff feedback shared through the provider’s most recent engagement report reflected a positive experience of inclusion. Comments included, “I’m satisfied with [the provider’s] efforts to support diversity and inclusion,” I believe [the provider] is a diverse workplace,” and “I’m confident I won’t be discriminated against at [the provider].”

This indicated a culture where staff felt safe, respected and represented. The provider also promoted inclusive values through day-to-day care delivery, with people using the service reporting that staff respected their background, culture and identity.

Regular team meetings and supervision sessions included updates on person-centred care and inclusive practice, supporting ongoing awareness and engagement in equality issues.

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.

While there were processes to monitor quality assurance, training, incidents, and staff compliance, and staff understood how to report concerns, these governance systems did not always effectively manage key risks. In particular, issues around medicine management and care planning were not fully addressed, despite action plans being in place.

Managers worked to ensure teams collaborated well and maintained relationships with external agencies, especially in emergencies. However, follow-up on incidents and lessons learned was not always thorough, limiting improvements and the prevention of repeated issues.

Overall, the governance and oversight arrangements were not strong enough to consistently ensure safe, high-quality care and risk management.

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.

Staff supported people according to their assessed care hours. While this meant individual outings were sometimes limited, the service made use of volunteers and group activities to offer extra support and engagement. People took part in events like gardening, seasonal celebrations, and group singing. Although no activities were happening during the visit, people told us they enjoyed them and looked forward to taking part.

The provider also held a health and wellbeing day. This included checks for blood pressure, diabetes, mobility, and medication, with input from healthcare partners. Staff also gave advice about falls prevention, hydration, and long-term health conditions, helping people stay well and independent.

People said they felt safe, cared for and supported. The provider worked with others to meet people’s health, care and wellbeing needs in a joined-up and person-centred way.

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.

Staff described the culture as open and supportive, with one saying, “My colleagues, team leader and manager are so helpful, I’m not afraid to tell them anything.” Staff had access to regular training and supervision and were encouraged to reflect and share personal development goals. Leadership responded to staff feedback and made changes such as improving infection control and adjusting activities to match people’s interests and routines.

However, learning was not always applied consistently in key areas. A medicines review found repeated issues with missing allergy details, vague or missing protocols for “as needed” medicines, and care plans that did not clearly reflect people’s support needs. These problems persisted despite additional training, audits, and an action plan, indicating that improvements were not always embedded in everyday practice. This limited the effectiveness of learning systems and left people exposed to avoidable risk.