Abbey Village

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 requires improvement. At this assessment, the rating has remained 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.

The provider was previously in breach of the legal regulation in relation to governance. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

This service scored 54 (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 had begun to develop a clearer vision and culture for the service, but this was not yet fully established or consistently understood by staff.

Staff did not always share a clear or consistent view of the service’s overall aims. Meeting minutes and supervision records showed limited discussion about common goals or how the team would work together to deliver them. This reduced opportunities to reinforce a shared approach in everyday practice.

Not all leaders understood the context in which the provider delivered care, treatment and support.

Leaders were visible and understood the service. Systems for supporting individual staff after incidents was not used effectively, and organisational learning was not consistently captured or shared. Although staff knew how to raise concerns, not all felt confident doing so, and Freedom to Speak Up arrangements did not provide an independent person within the organisation for staff to speak to. Staff and people's experience of management varied.

People did not always feel able to speak up or confident that their concerns would be heard.

Staff told us they understood how to raise concerns and could approach senior managers if needed. However, not all staff felt comfortable doing so, and some lacked confidence in the process.

The provider had taken steps to strengthen its Freedom to Speak Up arrangements by introducing a Raising Concerns, Freedom to Speak Up and Whistleblowing Policy. However, the policy did not meet best practice expectations. The provider had appointed the registered manager as the Freedom to Speak Up lead, which did not offer staff an independent route outside the management structure. This limited the effectiveness of the improvements and meant staff did not always have access to a fully impartial point of contact.

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

Some staff told us they did not always feel valued within the service. We received mixed feedback regarding this, and some staff did not feel that everyone received fair and equitable treatment. However, some staff said when adjustments were required, leaders responded and implemented changes to support their individual circumstances.

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.

We found inconsistencies and inaccuracies in people’s care plans. Although monthly reviews were taking place, these checks had not identified the concerns we found. Some health-related information recorded in care plans was not reflected in people’s daily notes, creating gaps in the overall oversight of care. We shared these issues with the provider, who told us they would review all care plans to ensure information was accurate. Related information recorded in care plans was not reflected in people’s daily notes, creating gaps in the overall oversight of care. We shared these issues with the provider, who told us they would review all care plans to ensure information was accurate.

There were also governance issues relating to DoLS paperwork. While applications had been authorised, the required documentation was not available within the service. The provider explained that this resulted from previous poor record‑keeping, but the absence of documents still indicated limited oversight and monitoring of the process.

We also found that some handover documents were not signed or dated, making it unclear when information had been communicated between staff. The provider acknowledged this and stated they planned to strengthen the handover process.

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.

Health professionals reported that the service was improving, with the manager implementing positive changes that supported better health outcomes for people.

During the assessment, we observed a range of health professionals visiting the service, demonstrating ongoing partnership working to promote people’s health and wellbeing.

Professionals told us that while “the standard of care could be better at times”, they had seen clear progress and noted, “The service is improving and the manager has made positive changes.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

Leaders showed a clear commitment to strengthening the quality of care. They had taken steps to improve systems and processes and recognised that further work was still needed. They had begun implementing changes to promote more consistent and safer practice however some areas still required improvement and time for this to be imbedded into the service.

The provider worked in partnership with the local authority to address specific concerns, including medication management. Training and development were encouraged, and staff were supported to complete learning linked to their roles, such as health and social care diplomas.

Overall, the provider had made progress and continued to embed processes designed to improve the safety and quality of the service.