Archived: Sovereign 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 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 of the service and continually reviewing and improving the service.

This service scored 25 (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, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people.

The provider had a positive culture policy in place but this did not reflect the needs of people using the service. The policy referred to good practice in supporting people with a learning disability and autistic people, however, no one living at the service had a learning disability or was autistic. The policy did not consider the specific needs of older people and people living with dementia. They did not understand the challenges people living at the service may face or support staff in delivering care which met people’s individual needs and preferences.

The provider reviewed and updated their statement of purpose after our site visit. This stated their aim was to, ‘To foster an atmosphere of care and support which both enables and encourages our residents to live as full, interesting and independent a lifestyle as possible with rules and regulations being kept to a minimum’. This aim had not been achieved, we found the care was task focused and people were not supported to live fulfilled lives.

The provider did not have leaders who understood the context in which they delivered care, or who embodied the culture and values of their workforce and organisation. Leaders had not maintained their skills, knowledge and credibility to lead effectively.

The provider and registered manager had not kept their skills up to date so they could lead a service which always delivered good quality care. They worked on the floor providing care as well as managing the service. This had taken them away from important management tasks such as keeping up to date with developments in social care and developing a skilled and competent workforce.

Staff meetings had been held but were poorly attended. The registered manager had not used the meetings, or any other strategies, to support staff to understand what good care looked like or how they were to provide care to meet people’s individual preferences.

The provider had not developed a positive culture where people felt they could speak up and their voice would be heard.

The provider and registered manager had not taken action to develop and maintain a culture of openness, honesty and transparency. They did not empower staff to drive improvement at the service. Staff were not regularly encouraged to raise concerns. They had not met with leaders regularly for supervision or staff meetings. Minutes of staff meeting showed they were held infrequently, were not attend by all staff and did not encourage staff to share and discuss any concerns they had.

A speaking up culture had not been developed where staff felt confident to raise concerns. For example, staff told us they did not feel it was safe for them to complete caring, housekeeping and cooking tasks during the same shift because of infection control risks. They had not raised these concerns with the provider.

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

The provider and registered manager had not acted to review and improve equality, diversity and inclusion at the service. They had not considered how they would create a fair, inclusive culture, which removed barriers to opportunities and support, regardless of staffs’ background. Leaders had not completed equality, diversity, and inclusion training to support them to identify and address any workforce disparities. There was a risk the voice of staff with protected characteristics would not be heard and they would be excluded or marginalised.

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.

The provider did not have systems in operation to check the quality of all areas of the service and address any shortfalls. Checks and audits had not been completed on many areas of the service, including care plans, risk assessments and fire safety and shortfalls continued unaddressed placing people at risk of harm. Some checks which had been completed, such as medicines audits, had not identified the shortfalls we found and again these continued unchallenged placing people at risk of harm.

The registered manager was not aware of when they needed to notify us of specific events which had occurred at the service, such as safeguarding concerns or serious injuries. We use this information to understand what is happening at the service and the action the provider has taken to protect people from the risk of harm or abuse.

The provider had not demonstrated their duty of candour by apologising to people and their representatives when things went wrong.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

There was a closed culture at the service and the registered manager and provider did not engage with local forums to understand changes in the social care landscape and how they would implement best practice to develop the service and improve people’s care.

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.

The provider and registered manager did not have an effective processes in place to understand how the service needed to improve and make those improvement happen. The service had not developed since our last inspection in March 2020. The provider told us, “We never really recovered from the Covid pandemic”.

The provider told us they planned to redecorate bedrooms when they became vacant and to recruit more staff so they and the registered manager did not have to cover care shifts. They did not have plans in place to develop the service in line with best practice such as the implementation of nationally recognised assessment tools and supportive environments for people living with dementia.