Broadoak Grange

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 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 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.

Discussions with the registered manager demonstrated they did not always have adequate oversight of care practices within the home. For example, they were unaware that staff were not consistently recording all care delivered in line with people's care plans. This, alongside ineffective governance systems, meant there was a lack of oversight and direction to drive standards, challenge poor practice and ensure people consistently received safe, high-quality care.

Improvements were required to the governance and quality assurance arrangements at the service. Audit processes were not sufficiently robust and had failed to identify a number of concerns found during the inspection. As a result, issues were not always recognised, monitored or addressed in a timely manner. This limited the provider's ability to learn, improve and maintain oversight of the quality of care being delivered.

It was also not clear how the provider's vision and values were communicated, understood and embedded across the staff team. Staff described a lack of a supportive and positive culture within the home and told us they wanted more visible, consistent leadership.

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 registered manager was responsible for managing 2 services and, as a result, was only able to spend part of their time at this home. Staff and the registered manager told us the registered manager had only recently started spending more time at the service following the deputy manager commencing a period of leave. This meant day-to-day leadership and oversight had previously been delegated to the deputy manager. As a result, the registered manager did not have sufficient oversight of the quality and safety of care being provided, the effectiveness of systems and processes, or the experiences of people living at the home.

Provider oversight was also ineffective. A recent area manager audit failed to identify many of the concerns found during this inspection, including shortcomings in medicines management, governance systems, accident and incident oversight, MCA processes and care records. This demonstrated that quality assurance systems were not operating effectively to provide assurance, identify risks or drive improvement.

Therefore, significant concerns had not been recognised, escalated or addressed by either service-level or provider-level leaders, demonstrating a lack of effective leadership, oversight and accountability to ensure people consistently received safe, high-quality care.

The provider had not created an open and inclusive culture where staff felt consistently confident to raise concerns.

Staff fed back they were apprehensive about speaking openly and described concerns about potential repercussions if they raised issues regarding the quality and safety of care. This indicated staff did not always feel assured their concerns would be welcomed, listened to and acted upon without fear of negative consequences.

This was despite the provider's own policy stating that staff were encouraged to speak up about anything that got in the way of doing a great job and that a Freedom to Speak Up Guardian was available to support staff where they felt unable to raise concerns through other routes. However, staff feedback did not reflect that these arrangements were operating effectively in practice, as staff remained reluctant to raise concerns openly.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had not always ensured staff were equipped with the knowledge and skills to promote equality, diversity and inclusion. Most staff had not completed equality and diversity training, which meant they may not have fully understood how to recognise and respond to people's diverse backgrounds, protected characteristics and individual needs.

Staff feedback indicated they did not always feel supported by the provider in relation to their own individual circumstances. Some staff expressed a lack of confidence that their wellbeing and personal needs would be considered appropriately. This suggested further work was required to create a more inclusive and supportive culture where staff felt valued, respected and able to raise concerns openly.

Leaders had not fully embedded equality, diversity and inclusion within the workforce. Improvements were needed to ensure staff received appropriate training, felt supported in their roles and experienced a culture that promoted fairness, respect and inclusion.

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.

Governance arrangements had failed to identify, assess and address significant risks, resulting in widespread concerns remaining unrecognised and unresolved.

Systems and processes designed to monitor the service were not operating effectively. Provider and service-level audits had failed to identify a range of issues identified during the inspection, including unsafe medicines management practices, inadequate risk assessments and care planning, environmental safety concerns, shortcomings in recruitment and staff competency checks, and failures to comply with the Mental Capacity Act and safeguarding requirements.

Management oversight of audits and quality assurance processes was ineffective. Audits and checks delegated to staff were either not completed robustly or were not effective in driving improvement. As a result, records did not accurately reflect the quality and safety of the service, and actions were not taken to address identified concerns. Risks to people's health, safety and wellbeing were therefore not consistently identified, monitored or mitigated.

The provider had also failed to foster an open and transparent culture. Feedback obtained during the inspection indicated some staff lacked confidence to raise concerns openly and were apprehensive about potential repercussions for doing so. This created a risk that concerns regarding people's safety and quality of care may not be escalated promptly, limiting opportunities for learning, improvement and early intervention.

The provider did not always 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.

Staff worked effectively with external healthcare professionals to support people's health needs. People received regular input from a range of healthcare services, including GP reviews and support from district nurses where required. A healthcare professional spoke positively about partnership working and told us, “Staff are proactive in getting people seen. Communication is good and they remember to chase things up.”

However, opportunities to support people to maintain links with their local communities and participate in meaningful community-based activities were not always maximised. The provider could not demonstrate a consistent approach to promoting community engagement and reducing the risk of social isolation. As a result, some people had limited opportunities to maintain relationships, pursue interests and remain connected to their wider community.

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. They did not actively contribute to safe, effective practice and research.

Opportunities to identify themes, share learning and implement improvements had been missed.

We found concerns identified during this inspection were similar to issues previously identified at another service operated by the provider. However, the provider had failed to demonstrate learning had been shared and embedded across services to reduce the risk of recurrence. This meant known risks and areas of poor practice had not been proactively addressed despite opportunities to do so.

The provider also failed to act on feedback from people, relatives and staff regarding a lack of engagement opportunities and meaningful stimulation for people living at the service. Concerns and suggestions raised about improving activities, social interaction and people's day-to-day experiences had not resulted in effective action or sustained improvements. As a result, opportunities to enhance people's wellbeing, quality of life and outcomes had been missed.

The lack of organisational learning and oversight limited the provider's ability to drive sustainable improvements and ensure consistent standards of care across its services. As a result, people remained exposed to risks that could reasonably have been anticipated, identified and mitigated through effective sharing of learning and best practice.