694 Pinner Road

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 inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant we identified shortfalls with the governance of the service. The model of care was not always in line with current best practice guidance right support, right care, right culture. There was a lack of effective auditing processes which has resulted in a breach of legal regulation in relation to good governance.

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 did not have a clear shared vision. Management assured us there are no issues related to workplace inequalities and some staff we spoke with shared similar views. However, we received mixed feedback from staff we spoke with regarding the direction of the service, areas for improvement and change. Some staff we spoke with told us the service did not foster a culture of openness and transparency and felt there was “favouritism” and “discrimination” present within the staff team. We raised this with senior leadership who informed us they will engage with all staff at the service to determine and discuss concerns to foster a more collaborative working environment moving forward and ascertain support staff may require.

The service manager had the skills, knowledge, experience to lead effectively. staff we spoke with told us the service manager was approachable and felt well supported. When the service manager and senior leadership were made aware of our feedback and concerns, they demonstrated a proactive approach in responding to these issues with the aim of making positive change and driving improvements.

Senior leadership told us the service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff we spoke with said they felt comfortable raising concerns to the service manager but did not have the confidence to raise concerns to senior leaders. One member of staff told they were “Scared to speak up or we will lose our job.” We discussed this with the provider who has already started making changes within senior leadership to create a culture where staff feel more comfortable speaking up about concerns.

The provider valued diversity in their workforce. They worked towards an inclusive culture by improving equality and equity in recruitment processes. The provider regularly reviewed their policies to promote equity in the workplace and recognised different cultural holidays and awareness months. The service manager told us the service hosted events that would highlight different cultures and backgrounds.

The provider did not have clear systems of accountability and good governance in place to identify and drive improvements within the service. The auditing processes were ineffective relating to care records, restrictions imposed on people and assessing risk. We identified gaps in records which should have been identified by the provider’s internal auditing and quality processes. The service did not always ensure sufficient action had been taken to improve governance systems in place to assess, monitor and mitigate risks to people.

The service did not always understand their duty to collaborate and work in partnership so that services worked seamlessly for people. They did not always share information and learning with partners. For example, the service did not always share safety concerns with relevant authorities in a timely manner which could impact on the quality of care being delivered. This meant that partners may struggle to ensure that support was always appropriate.

The service 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 which could impact on the overall safety of the people who lived in the service. For example, when accidents and incidents occurred, there was little evidence to show corrective actions taken and preventative measures to mitigate recurrence. Incident follow-up processes were ineffective, and lessons learnt were not proactively shared across the staff team, management and leadership to foster an overall culture of safety and continuous learning.