Nevin 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 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 oversight at the service.

This service scored 50 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The provider did have policies in place in line with best practice however they were not always meeting these. For example, in relation to people’s needs in relation to their learning disability and autism. Staff and manager meetings were held. However, these did not cover discussions around the service’s vision, values or a focus on learning and improvement were evident.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. For example, the provider was issued with an improvement plan from commissioners which included actions to complete to enable improvements to people’s care. However, we found continuing themes of concerns and ongoing issues during our inspection which had not been completed. Failure to act upon some of these actions or ensure improvements were embedded into practice had impacted the quality of care for people. Staff and relatives informed us leaders were friendly. However, a relative told us they had not met the registered manager and would like the opportunity to do so. It has been identified by the provider that the interim manager needed additional support to effectively manage the service but recruitment for a deputy manager was ongoing.

The provider fostered a positive culture where staff felt they could speak up and their voice would be heard. The provider had relevant policies in place in line with current best practice guidance such as a raising concerns, freedom to speak up and whistleblowing policy and procedures. Staff informed us that they felt confident to report things if needed and that action would be taken should they have concerns.

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. For example, a member of staff wanted to be given additional overtime hours. The interim manager stated that they would have to consider the rest of the staff team to ensure fairness in allocating overtime. Another staff member requested specific working days for religious purposes which the interim manager took into consideration and considered the needs of other staff and the people using the service. Staff had not undertaken equality, diversity and inclusion training at the time of our inspection. However, the provider took appropriate action to address this following our inspection.

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’s quality assurance systems had failed to identify areas of concern we found during our inspection. For example, storing and auditing of medication, health safety and staff training needs. Quality assurance systems were not robust. For example, monthly fire safety log for January 2025 identified, ‘Fire doors needed to be looked at as they can sometimes struggle to close’ and ‘Door may have been misaligned due to age of the doors.’ The provider actioned this as, ‘Fire doors to be assessed (Book repair for next week)’. However, some fire doors were still not fit for purpose when we inspected. Failing to have effective oversight of the service placed people at increased risk of harm.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. People were not always offered opportunities to attend any community groups or activities to improve people’s emotional and social wellbeing and build community relationships and improve people’s networks. Feedback from commissioners told us they had experienced delays when receiving information from the provider.

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. Leaders failed to recognise safe and effective practice and therefore were unable to continuously improve the service. Providers did not always seek and therefore act upon feedback from external partners. People were not actively involved in reviews of concerns, accidents, incidents and adverse events and in planning to prevent similar incidents in the future.