Welcome House - Leeza Court

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 good governance, and failure to submit statutory notifications

This service scored 29 (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 and their communities. We identified a closed culture at Leeza Court. A closed culture is a poor culture in a health or care service that increases the risk of harm. This includes abuse and human rights breaches.

The provider had not acted with candour to safeguard people when allegations of abuse or neglect had been made. They did not ensure people with complex mental health conditions had robust care plans in place to proactively promote their wellbeing or ensured that all appropriate steps had been taken to protect people from the risk of harm. There was not a common understanding of how staff should act to protect people from harm, respond if people were distressed or support people’s mental wellbeing. People had restrictions placed on them without it being clearly documented how these were reached, why they were in people’s best interest or how they were the least restrictive option.

Leaders did not understand the context in which the provider delivered care, treatment and support. They did not embody the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

There had been failings at leadership level to act with candour and openness. Where people had raised allegations of abuse, these were not reported as safeguarding concerns on the basis that some people made allegations that according to leaders were demonstrably false. The service did not recognise this could potentially increase the risk of genuine abuse or neglect going unchallenged. Where staff had allegations of abuse made against them, the provider did not take sufficient action to safeguard them. For instance, we heard examples of people making frequent allegations of abuse about staff, but when staff asked for another member of staff to be present as a witness, this was not consistently put in place. In some cases, we heard other people who lived at the service asked to go into the private areas of their peers to act as a witness to people’s care in the absence of staff members, which was inappropriate. There was a poor understanding of the importance of having robust care plans and risk assessments in place to ensure the provision of seamless and proactive mental health support to people. People lived with complex mental health conditions without a clear plan of how staff or the service would support them.

People did not always feel they could speak up and that their voice would be heard. Many staff told us they felt management were approachable. One staff member told us, “The manager is really good. I can speak to him at any time any day and wouldn’t hesitate to do so”. Staff could identify other organisations they could contact such as CQC or the local authority and stated they could also speak to the operations manager.

However, another member of staff told us, “When I have raised concerns previously these have not been acted upon”. Although many staff told us they felt comfortable to speak up, we found this has not happened in practice because the service had failed to report allegations of abuse or neglect. We found there was a closed culture at the service where management had not always acted with openness or integrity. A closed culture means a poor culture that can lead to harm, which can include human rights breaches such as abuse.

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. We saw that where racist abuse had been directed at staff, management had not taken sufficient action to address this, such as arranging anti racism workshop events for people. Where staff felt uncomfortable supporting a person, they were able to express this and would be allocated to other individuals or services within the same provider for their own wellbeing. We received mixed feedback from staff on whether they felt supported when they were a victim of discrimination or abuse. The common feedback from staff was that being a victim of racist abuse was just an accepted part of the job, and they would have to tolerate this. One staff member told us, “It’s normal for a service for people with a mental health condition, we have to put up with it”. No person should feel in a position where they feel they have to accept routine racist discrimination and the provider needed to do more to counter this.

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. Leaders had failed to understand or fulfil their regulatory requirements and notify CQC of potential safeguarding concerns which they are required to do. Leaders had failed to notify CQC of incidents, events and changes that affect a service or the people using it, such as abuse or allegations of abuse.

Though audits and governance practices were in place, these were not robust and had failed to identify that people were being exposed to significant risk of harm due to staff lacking adequate guidance in safely managing people’s complex mental and physical health needs. People’s care records did not always reflect their current needs, and the provider had failed to identify or manage all risks to people’s safety and wellbeing. Although there was a business continuity plan in place regarding how the service would respond to an emergency such a fire, this was based on the false assumption that people did not smoke in the building. It had not been identified that staff did not have a consistent understanding of how to support people, or been given clear guidance to ensure people received safe and evidence-based care regardless of who was supporting them.

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. We observed some positive examples of the service working in partnership with their wider community to support people’s needs. The manager regularly attended meetings with other local care homes through a forum organised by the GP Practice to share best practice, and was also a member of the local Skills for Care Registered Managers network which they used to request advice from their peers where they faced challenged. There were referrals made proactively for some people, for instance the service were currently working to arrange a visit from alcohol support services for one person and had ongoing support from dieticians around people who had an eating disorder. However, we could not be assured that effective pathways were always in place for all people’s needs. For people’s mental health conditions, there was a lack of clear evidence-based guidance from professionals on how staff should support them. For people’s physical health needs, there were a wider range of conditions where there was no information at all about how staff could meet these needs or at which point advice from other professionals should be sought.

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. Although incidents were documented and investigated, there wasn’t a clear analysis or themes or trends, and this information wasn’t used effectively to prevent future recurrence. Where incidents did occur, people’s care plans were not updated to ensure staff had a clear plan to support people safely. For example, people had been recorded as being physically aggressive without any clear plan on how staff should respond to this, and people were assessed as not being described at risk of self-harm or suicide despite evidence to the contrary.