Abbeygate

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 service was in breach of legal regulation in relation to the governance of the service.

This service scored 62 (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 inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager had the skills, knowledge, and experience to lead the service effectively and were open, honest and responsive during this assessment. Whilst we found leaders at all levels were visible within the service and they led by example, we found they had not always identified issues we found during this assessment. The management team knew the staff well, which meant prompt action could be taken where necessary to support staff. Most people and staff spoke positively of the management team and told us they had opportunities to provide feedback and could raise any concerns or suggestions. One staff told us, “I can’t fault the management, they are brilliant. They are fair to all of the staff.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager had the skills, knowledge, and experience to lead the service effectively and were open, honest and responsive during this assessment. Whilst we found leaders at all levels were visible within the service and they led by example, we found they had not always identified issues we found during this assessment. The management team knew the staff well, which meant prompt action could be taken where necessary to support staff. Most people and staff spoke positively of the management team and told us they had opportunities to provide feedback and could raise any concerns or suggestions. One staff told us, “I can’t fault the management, they are brilliant. They are fair to all of the staff.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The service had processes in place to support people to speak up. Records demonstrated resident and staff meetings take place regularly and provide an opportunity to speak up.

Staff told us they felt able to raise any issue with the management team and felt they would be listened to.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.The service had a Christian Church ethos; however, the management team informed us they respected people’s different religious and cultural beliefs. There was a strong ethos at the service of treating people as individuals, this extended to the workforce as well.

Staff felt they were treated as individuals and their needs were taken into consideration, such as shift times being arranged to fit in with studying and family commitments. The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. There was an open and inclusive recruitment procedure. The management team described how they recruited staff based on their compassionate natures, skills and experience. Care staff were positive about working at Abbeygate and would recommend it as a place to work.

The provider did not have efficient systems to ensure good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

During the assessment, we found governance and accountability systems were in place but not always effective. Governance systems had been effective at ensuring some of the issues identified at the last inspection had been addressed.

A range of checks and audits were in place to monitor the quality and safety of the service. These included an overarching service led audit conducted by the registered manager on a monthly basis. The audit included areas around the environment, care plans, infection control, medicines, nutrition and hydration. However, these governance systems were not always effective in identifying and addressing issues we found during the assessment in relation to risk assessments, environmental risks, staff training and supervision.

There were systems in place to identify environmental issues and a recent provider audit had identified some of these issues. However, this had not been acted upon.

Whilst we found no concerns with the staffing within the service. We were not assured there was a robust system in place to ensure staffing levels were regularly assessed and monitored to ensure there were enough staff at the service. We observed positive interactions between majority of staff and people however, we did observe some staff being task orientated with little interaction towards people, for example one staff member supported an individual, however there was no interaction with the individual.

Oversight of training records had not been kept up to date. We found staff had not completed or refreshed training in key areas as stated in this assessment.

Policies and procedures had not been updated to reflect current practice. Recruitment records showed Disclosure and Barring Service (DBS) declarations were signed and completed by staff. This was not in line with the provider’s policy. The policy stated Disclosure and Barring Service (DBS) checks needed to be carried out and staff needed to register with the update service. The registered manager and provider corrected their policy after the assessment.

The management team were receptive to our findings and undertook action to make improvements.

The provider understood their duty to collaborate and work in partnership so that services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Staff were aware of other professionals involved in people’s care and worked alongside them when needed.

The management team expressed an open positive attitude to receiving support and understood how and where they could access support. Staff told us they were usually able to support people to access the community. A person asked for support with this, and this was provided immediately.

The provider did not always focus on continuous learning, innovation and improvement across the service and local systems.

Systems were in place for learning and improvement. These included resident meetings, team meetings, surveys, supervisions and audits. However, they had not resulted in improvements in all of the areas identified by the provider’s audits as already stated in this report. Learning had not been embedded and people were at risk of incidents and accidents happening again. The management team were open to feedback and took action to address the concerns we identified immediately.