43 Station 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 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 good governance.

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.

The provider lacked a clear vision, strategy, and culture rooted in transparency, equity, equality, human rights, diversity, inclusion, and engagement, though they understood community needs and challenges. Support plans were thorough and gave staff clear guidance, but non-verbal communication methods were not consistently applied. The manager aimed to improve training and ensure consistent use of these methods, reflecting on their own ability to support staff effectively.

We found that there was little encouragement for people to try new experiences. The Manager stated their aim is to collaborate with individuals, relatives, and healthcare professionals to create personal profiles and seek new opportunities.

The recently appointed manager had not yet had enough time to set clear strategic goals or clarify how staff roles aligned with the broader objectives of the service. The manager showed a strong grasp of the provider's values, stating, "The people we support are individuals, not just entries in a textbook." They discussed plans to collaborate with others and innovate in care and support by 'thinking outside the box'. According to staff, recent management changes led to improvements in documentation throughout the service. Recent team meetings included updates about people’s needs, lessons learned from incidents, feedback from audits, and management visits. Staff were also encouraged to share their thoughts and discuss any challenges they encountered. However, after the management change, regular team meetings had not been held. The manager explained that these meetings would now occur every two months.

The provider had inclusive leaders 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.

A new leadership team supported the team. They had taken action to stabilise the service and improve quality. Leaders and managers demonstrated the skills, knowledge and experience required to deliver quality care to people. Managers were present and accessible, actively fostering an inclusive culture and exemplifying the organisation's values.

There were systems in place to ensure the capability of leaders and managers. Managers were supported through appropriate training, supervision and development opportunities. Staff told us that leaders were approachable, listened to them and encouraged a culture of transparency.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff said their concerns or suggestions would be heard. Team meetings had been held to share information and provide staff the opportunity to input into how they delivered care and support for people. The manager told us these were scheduled every other month to ensure regular communication and oversight.

Managers said staff confidently raised concerns with them. Staff told us they felt valued and they had been invited to provide feedback through yearly surveys. The manager told us they wanted to increase completion rates and ask staff for feedback during supervisions.

The provider valued diversity in their workforce and was working towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Since the interim manager joined the service, they told us more staff had requested reasonable adjustments to their working hours. The manager identified the need to review one-to-one hours for people using the service to ensure these adjustments could be met without compromising support. The manager provided examples where people’s working patterns and hours had been adapted to meet their specific needs and us how this had also improved staff morale. This meant the application of reasonable adjustments was not yet consistent, which could leave staff without the support they needed to perform their roles effectively.

Leaders promoted involvement from staff, although internal audits identified that staff contributions were not consistent. Leaders told us staff were motivated and enthusiastic about their roles following the change in management. They were encouraging staff to take on champion roles and additional responsibilities. This provided development opportunities for the team and steps to strengthen recognition.

Managers used values-based interview questions during recruitment to appoint staff who shared the providers vision for supporting others. This approach helped leaders consider behaviours and alignment, rather than relying on experience.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. However, they acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Audit systems for medicine management were not consistently effective and did not provide sufficient assurance. Although staff completed audits, they had failed to identify and escalate concerns of the storage temperatures of medicine, which was identified on our visit. The manager took prompt action to address this and implemented additional measures to strengthen monitoring arrangements.

In other areas, quality assurance systems implemented were working well to review health and safety actions and improvements to the environment. Managers had also developed detailed contingency plans and actions for staff to take in the event of an emergency.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

We found that the provider had not consistently involved people, or their relatives, in planning, reviewing or developing care that supported them to remain connected to their community. Records did not reflect how opportunities were promoted. This meant partnerships with community groups and local resources was under-utilised and limited people’s opportunities. Relatives understood a new manager had just started at the time of the assessment and were keen to be more involved in the delivery of care and support for people.

The manager had a good knowledge of local health and social care partners, alongside demonstrating a clear commitment to exploring and strengthening relationships. The manager recognised the need to involve others more consistently in care reviews and service development. The provider worked with professionals where people had specific long-term health conditions.

The provider understood their duty to focus on continuous learning, innovation and improvement across the organisation and local system.

Following recent changes in management of the service, the provider had taken action to address shortfalls which had been identified since the former manager left. The provider had systems in place to carry out internal audits. However, these did not identify all areas where care was below expected standard. Following concerns identified during the inspection, the manager took prompt action to review processes and improve the safe storage of medicines.

In response to other identified areas of concern, the manager has held a team meeting and outlined clear expectations for staff to follow and ensure consistent practice. The management team told us they were committed to improving the quality of care within the service. This included focusing on developing consistent non-verbal methods of communication, exploring new opportunities for people and supporting staff to develop skills and knowledge.

Staff were encouraged to contribute ideas for improving the environment and people’s experience. The interim manager told us how they worked with people to personalise communal areas of the home, including the use of themed stickers and decorations.