Archived: Borough of Lewisham

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• 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

During our assessment of this key question, we found the provider had failed to effectively assess, manage, monitor and improve the quality and safety of the service, which was an ongoing breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We were not be assured that leaders had the skills, knowledge and credibility to lead effectively.

We were not assured the registered manager had provided accurate information about staff employed.

The arrangements for the availability and integrity of data was not robust and we could not be assured information was used effectively to monitor and improve the quality of care.

The governance, management and accountability arrangements and staff roles and responsibilities were not clear. We could not be assured managers could account for the actions, behaviours and performance of staff.

There were quality assurance process in place but these were not effective and the issues with risk management, staff support and training and the overall quality of records had not been identified and/or resolved.

Despite the issues we found we received positive feedback staff.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

At the last inspection staff told us the culture of the organisation was not fair and open and some staff said there was a culture of bullying. This aspect of the service had improved and we received positive feedback from staff about the culture of the organisation. We received comments such as, “The registered manager is doing her best. I think they are very supportive” and “I’ve got no concerns with the company.”

Due to the poor quality of care records, we could not be assured leaders have the experience, capacity, capability and integrity to ensure risks were well managed.

Due to the conflicting information across staff supervision records we could not be assured leaders were visible and lead by example.

The registered manager could not provide evidence that they were keeping up with skills and knowledge required to manage the service and train staff.

The registered manager had not provided accurate information about staff employed. The provider gave conflicting and contradictory information about their employment and conflicting reasons why they could not provide the evidence of safe recruitment.

Due to the issues we found with recruitment we could not be assured high-quality leadership was sustained through safe, effective and inclusive recruitment and succession planning.

We could not be assured leaders were knowledgeable about issues and priorities for the quality of services. The provider had been working towards improvements, but we found issues remained with the quality of records and the management of risks. Records related to care and support and the management of staff were poor quality and contained numerous errors and contradictions.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager informed us they had been supported by an external consultant during the local authority provider concerns process. Care staff told us they understood their role and could get support from the registered manager if they needed to.

At the last inspection the provider did not effectively assess, manage, monitor and improve the quality and safety of the service. This was a breach of regulation 17.

Insufficient improvement had been made and the provider was still in breach of regulation 17.

The governance, management and accountability arrangements were not robust and staff roles and responsibilities were not clear. We identified several staff that had been recently employed at the service. The registered manager gave us conflicting reasons why they could not provide the information about these staff. When information was provided it was incomplete and roles and responsibilities of these staff was conflicting. Some staff had been carrying out of range managerial duties. One member of staff had also been employed to deliver care and support.

The systems in place to monitor staff performance were not robust. The registered manager told us they regularly contacted staff to check on their welfare. However, there was no record of these routine checks so we could not be assured the process was effective.

The arrangements for the availability, integrity and confidentiality of data were not robust. The registered manager could not always locate documents we requested. Documents submitted were sometimes blank, duplicated, mislabelled or illegible. Some records related to staff recruitment had been inadvertently destroyed.

The management of current and future risks was not robust. The provider had a process of audits and quality assurance checks but these had not been effective and had not identified the issues with records we found. Audits contained multiple dates of completion and the errors and contradictory information in relation to care needs and risks.

The poor governance of the service increased risks to people's health and safety. This was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The experience of staff employed had improved since the last inspection. We received positive feedback. There was a strong sense of trust between leadership and staff.

Staff told us they felt listened to and had opportunities to share ideas and raise concerns. They knew what to do if an emergency arose. The provider told us they had been making improvements with the support of 2 consultants.

At the last inspection the provider was failing to effectively assess, manage, monitor and improve the quality and safety of the service. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Not enough improvement had been made and the service was still in breach of regulation 17.

Improvements achieved with support from the local authority and an external consultant had not been embedded or sustained. The provider’s improvement plan set out several actions that have been identified in response to the previous inspection. However, the lessons learnt from these processes had not been sustained and actions that had been recorded as completed continued. For example, a key area of leaning had been the provider’s process for storing and labelling digital records. The improvement plan stated this had been resolved but we found widespread issues with the quality and accuracy of records.

There were processes in place to gather feedback from people receiving care and staff. However, due to how these had been completed we could not be assured of their effectiveness. One staff member had completed a feedback survey before they started employment so we could not be assured feedback was meaningful. The provider had not carried out any analysis of the feedback in order to drive improvements.

One client feedback form contained multiple dates so we could not be sure when it had been completed. The answers provided were from a range of different people.

Staff meeting minutes were confusing as one document was used to capture evidence of several different meetings. Due to this it was not clear who attended, what agenda items were discussed and what actions have been set and completed.

The lack of effective monitoring and improving the service increased risks to people's health and safety. This was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.