Newgate Lane

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 remains the same. 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 this legal regulation in relation to good governance. Some improvements were found at this assessment; however the provider was still in breach of this regulation.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While the provider has established a clear vision, strategy, and culture promoting transparency, equity, equality, human rights, diversity and inclusion, and engagement, observations and team meeting minutes indicate that these values are not yet consistently embedded across all staff and practices.

Observations and some documentation suggest while many staff members demonstrated a positive and collaborative approach, this was not consistent and did not demonstrate a cohesive, inclusive and compassionate culture. Managers had not identified and worked to reduce restrictive practices to protect people’s rights.

Team meeting minutes, as recorded by the manager, show staff were reminded to provide compassionate care and follow care plans. However, the terminology used, sometimes emphasising accountability and potential consequences indicates that a consistently professional, positive culture and shared vision were not fully embedded across the team. This was supported by our observations on site.

Overall the provider lacked a unified and value-driven culture with inconsistencies in compassion, communication, and staff engagement which may impact the quality and safety of care.

Leaders did not consistently demonstrate the skills, knowledge, or understanding required to lead the service effectively. They did not always embody the values of the organisation or promote a culture that supported best practice.

Although there was a clear management structure in place and the registered manager reported feeling supported by the regional director and quality team, not all leaders demonstrated a full understanding of the context in which care, and support were delivered. The registered manager had relevant experience in supporting people with learning disabilities and was undertaking a professional qualification. Despite this, inspection findings and staff meeting records indicated that best practice was not consistently applied, particularly in relation to consent and the Mental Capacity Act. Concerns were also raised about the overall culture of the service.

Staff described the registered manager as visible in the service and told us the registered manager had, “Excellent management skills and tries her best to do all she can for her staff and people living here, has a real passion.”

The provider did not always foster a culture where staff were supported to access all available routes for raising concerns, with guidance and discussions primarily focused on internal processes.

The provider has a “speak out” policy in place. Records from team meetings and staff discussions show that guidance to staff focused on raising concerns internally, including through team meetings, supervision, and discussions with the manager or regional manager. References to external reporting routes, such as contacting CQC or local safeguarding authorities, were limited.

While staff reported feeling able to raise concerns, the emphasis on internal mechanisms may not fully ensure that all staff are aware of the full range of options for speaking up safely and appropriately. This reflects a shortfall in consistently promoting a culture where external reporting is clearly encouraged.

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.

Staff told us, “Management are very open to listening, very good flexibility with work, the management are great at supporting staff” and “A few weeks ago, I had some bad news, the manager knew I was feeling really low and has been really supportive.”

The provider had an equality and diversity policy, and staff had completed equality, diversity and inclusion training.

The provider did not consistently demonstrate effective governance arrangements.

The provider had implemented a new overarching governance system, incorporating findings from audits conducted by the registered manager, quality team and regional manager. Any required actions were logged on to the system and monitored until completion. A business continuity plan was in place, indicating some preparedness for operational disruption.

Despite these structures, several concerns identified during the inspection had not been detected through internal processes. These included gaps in consent documentation, incomplete records relating to risk, and non-compliance with the Mental Capacity Act (MCA). This highlights that existing oversight systems were not sufficiently robust to identify several key areas of concern.

Staff expressed generally positive views about the service. One team member commented, “I think it has room for improvement as every service should but as the team and manager are doing quite well, things are going well, and people live the best they possibly can.”

The provider was previously in breach of this legal regulation in relation to good governance. Some improvements were found at this assessment; however, the provider was still in breach of this regulation.

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.

The registered manager ensured relevant information was shared with people’s relatives and external professionals when required. A professional told us “The manager consistently includes me when best interest decisions are required” and “Whenever I have contact with the manager, I have been impressed by her professionalism and in particular her person-centred approach towards the residents.”

Staff supported people to attend appointments and activities in the community. Staff had recently researched sensory rooms in the community and had supported a person to attend this to see if they enjoyed it, with a plan to book further dates in the future.

The provider did not always identify and focus on continuous learning and improvement across the service.

Processes in place to review and identify any learning and service improvements following incidents, internal and external audits were in place. These were held on 1 central system to ensure management oversight both within the service and regionally. Processes were not always followed to identify learning and continuous improvement from incidents, therefore could not be reflected in the overarching improvement plan.

The registered manager was aware of where some improvements were needed, however the continuous improvement plan did not include all the areas we identified including the need to consent.

There were staff incentive schemes available including a regional employee of the month scheme and a high 5 scheme which recognised staff’s achievements.