Archived: Quenby Rest Home

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 at the service.

This service scored 25 (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.

The providers website, statement of purpose and service user guide referred to ‘values that really make all the difference to people using the service, as quality, respect, integrity and service’. However, there was no shared strategy developed in collaboration with staff and people who use the service to achieve these goals. Managers and staff were not aware of the vision, values or strategy to buy into to help them understand their roles and demonstrate how they would apply the values in their work to improve and develop the service. Managers had not actively developed and involved staff to improve the culture and quality of the service to ensure people received safe, high quality and compassionate care.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied 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.

Managers did not demonstrate they had the experience, capacity and capability to ensure the organisational values could be delivered and risks to people’s safety were well managed. They had not kept up to date with best practice guidance, and changes in legislation to ensure the service was able to meet the basic ‘fundamental standards’ of safety and quality. Managers had not built networks with other organisations and local initiatives, including local provider or manager forums to share knowledge, good practice happening within the wider care sector and to get help and support where needed. Staff told us managers stayed in the office, most of the time. We observed the deputy manager did help staff occasionally, but staff told this was not normally the case. The registered manager was not visible in the service and did not lead by example to promote good practice to staff.

Staff did not feel they could speak up and that their voice would be heard. Managers did not promote a culture where staff felt able to speak up about concerns, or where things had gone wrong. Where staff had recognised poor practice, they told us they were not confident to raise concerns due to the fear that they would be blamed or treated negatively if they did so. Staff told us they did not feel encouraged or supported to speak up about issues, if they did, they felt their concerns were not always listened to. Staff supervision records showed concerns about staff incidents, performance and disciplinary procedures had not been managed well or dealt with openly and transparently.

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.

The service employed a diverse workforce under the sponsorship scheme. Language may be a barrier for someone whose first language is not English. We found training was not pro-actively planned for where there were inequalities in staffs’ abilities and opportunities for learning and development. The training matrix and conversations with staff confirmed most training had been provided via computer based, eLearning. Through discussion with staff and our observations, we found disparities in staff comprehension of training provided. Where staff could not evidence understanding of the training they had received and were experiencing difficulties with professional language and the computer systems, no additional training and support had been provided.

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.

Systems to assess and monitor the quality and safety of the service were ineffective. These had failed to to ensure compliance with regulatory requirements and to keep people safe. Managers were not supported by the provider to recognise and achieve required levels of service improvement. There was a lack of oversight of the day to day running and safety of the service.

There were no clear and effective arrangements to assess the quality of staff training to ensure they had understood the content and test their skills, knowledge and competence. Supervisory arrangements did not support staff development to ensure they had the skills and ability to deliver safe care. Supervision was not provided regularly enough to provide the level of on-going support to new and inexperienced staff to create a skilled and effective workforce.

The senior management team were unable to demonstrate how they assured themselves the service was safe, fit for purpose and that people were receiving appropriate care. There were no proper processes in place to monitor the effectiveness of the RTH enablement scheme. Audits had failed to identify, capture and manage risks found during this assessment, including concerns about risks to people, staffing, staff training, fire safety, the premises and infection control.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

The provider and manager have worked well with CQC, and other professionals to make immediate improvements to ensure people’s safety following our assessment. However, failure to have systems in place to assess, monitor, and improve the quality and safety of the service had placed people at harm, and at significant risk of harm occurring. In response to feedback from our assessment the provider has employed the services of an external consultant to help drive the required improvements in the service.

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. They did not actively contribute to safe, effective practice and research.

Managers lacked understanding around the principles of effective auditing to review and analyse information to identify the strengths and weaknesses of the service, and make improvements happen. Investigations into incidents, accidents and safeguarding concerns had not been used as an opportunity to learn from what went wrong and make improvements to prevent similar incidents occurring. Trends, themes or root causes of incidents had not been looked for, such as identifying and addressing falls at specific times of the day. There was no system in place to encourage staff reflection and learning from safety events, such as a recent choking incident to discuss where things had gone wrong, and what needed to happen to prevent such events happening again.