The Haven

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 good governance.

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 shared vision, strategy and culture based on transparency.

The registered manager acknowledged there had been some cultural challenges and said they felt this was improving.

We received mixed feedback from staff and found a culture of individual blame rather than an open culture that was reflective and proactive, accepting of diversity and actively using staffs’ strengths. For example, we observed things going wrong during this assessment and the was instant blame towards individual members of the staff team.

A staff member said, “The Haven is a place where staff do as they do, for as long as they have, and change is not high on their ‘must do list’, things seem to work better when inspections are due, or after they have been completed.”

Another staff member said, “I feel sometimes there can be a bit of an atmosphere, due to a couple of staff members, who have always got something to moan about, this sometimes can bring you down.”

There was not a culture of risk mitigation through effective management of health and safety, this included environmental and fire safety concerns, for example, obstructed escape routes, storage of hazardous substances governed by the Control of Substances Hazardous to Health (COSHH) Regulations 2002, and risk to people who use wheelchairs.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not demonstrate they have the skills, knowledge, experience and credibility to lead effectively.

Leaders did not consistently maintain oversight of service performance or demonstrate a clear understanding of the challenges facing the service. We received mixed feedback from relatives and staff about leadership approach demonstrating a lack of consistency.

Quality assurance and governance systems had not identified several concerns found during inspection, including oversight of medicines, environmental risks and DoLS processes. This limited leaders' ability to demonstrate effective operational oversight and provide assurance.

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

We received mixed feedback which included, a family member saying, “I feel complaints are given lip service.”

A staff member said, “I am not convinced that speaking up makes much difference at the Haven, I believe that people have things done the way they like it done, and there's not much scope for change through voicing your options.”

Another staff member said, “I have no problem with saying what I feel to the management or in meetings.”

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We found that some staff did not always receive regular and supportive supervisions. Where staff had disclosed health conditions as part of their well-being, there was no discussion around adaptations to their role that might improve their ability to work and there were no risk assessments in place to ensure staff were working safely.

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, or share this securely with others when appropriate.

The provider had clear policies in place detailing who was responsible for key areas of governance. However, their systems had failed to identify when these key people were not working within the policies. For example, in a discussion with the named health and safety lead we were told they do not have health and safety meetings. We found widespread concerns with health and safety and risk mitigation at The Haven, so we were not assured that the named person had oversight of health and safety or that the provider had clear systems of accountability.

Systems were not used effectively to ensure compliance with regulatory requirements. Where we identified issues during the inspection the provider had taken action to address these, however, their governing strategy was responsive rather than proactive and did not consistently support keeping the service running well. This reduced assurance that improvements would be maintained and embedded over the longer term.

Quality assurance processes had not identified concerns relating to medicines management, including incomplete medication administration records, medicines audits, oversight of returns and stored medicines, environmental safety and compliance with regulatory requirements. Records were not always accurate, or complete, and leaders were unable to demonstrate that information relating to people's care, health outcomes and service performance was routinely analysed to drive improvement.
 

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.

A stakeholder said, “From my brief visits I see the staff being polite and friendly towards the residents. I have had no reason to make a complaint, any concerns I have I discuss openly with the manager or deputy manager.”
 

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.

Whilst leaders responded positively to feedback during the inspection and took action to address some concerns, there was limited evidence that learning from incidents, complaints, safeguarding concerns, audits and day-to-day monitoring was routinely analysed and used to drive improvement. Lessons learned reviews were not always fully completed and some incidents such as assisted falls were not investigated.

We found missed opportunities for improvement including for the oversight of medicines following on from a serious medicines error.

We also found significant combustible waste being stored along an external fire route in the same area that the provider had previously been told to clear and had actioned but not sustained. As a result, the provider could not consistently demonstrate that learning was embedded into practice or that quality improvement processes were being used to enhance people's safety, wellbeing, independence and quality of life.