Magdalen Close Hostel

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 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 governance at the service.

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The provider did not demonstrate a clear and consistent direction for the service, operating both long-term residential care and transitional placements for people who would soon move on to more independent housing. The vision for the model of care was not well defined or consistently understood across the team, or by some relatives. For example, 1 relative told us, “I am not happy [person] is moving. I’d love [person] to stay,” and, “Apparently, [person] can only stay 6 months… Some [people] have been there for years. Why are they there longer? It’s so hard to change. [Person] loves routine.” Leaders acknowledged this lack of clarity and confirmed the Statement of Purpose would need updating to reflect the scheme’s purpose and strategic direction. Staff told us they were committed to people and worked hard to create a positive environment, but several longstanding operational challenges had affected the service’s culture. These included building works impacting office space, the loss of administrative support, and the ongoing shift to new digital systems, which had disrupted routine oversight and contributed to uncertainty among staff about service priorities. Despite these concerns, staff described a culture that was caring and centred on supporting people well. The registered manager told us, “We are very open here… we have a good relationship with our parents”, reflecting a focus on maintaining a positive and inclusive culture despite unclear strategic direction. Another staff member told us, “We do what we can to help [person] flourish.”

Not all leaders understood the context in which the service delivered care, treatment and support. Leaders did not always have the skills, knowledge, and experience to lead effectively. However, they were open, transparent and committed to continuous improvement and sought to embody the culture and values of their workforce and organisation. The new manager had only been registered with the CQC for 3 months, and had inherited multiple issues, including gaps in governance systems, outdated processes, and the absence of a full-time administrator. This was combined with a complex service model which was not clearly defined, and a large number of people supported moving in and out of the service with a wide variety of differing support needs. The management team acknowledged these challenges, which affected their ability to maintain robust oversight. Although the management team was described as approachable and caring, there were weaknesses in some essential areas of leadership practice. For example, clear gaps existed in staff recruitment processes, and the absence of systematic audits of care plans, daily notes and incidents had led to some outdated practice and language used by staff. Leaders confirmed these checks had not been in place and accepted changes were required. Staff consistently praised the compassion and visibility of leaders. One staff member told us,“[Registered manager] is very good to talk to about any situation.” Another staff member told us how the registered manager and deputy manager, “Have been nothing but supportive”, reflecting the positive interpersonal relationships within the service. However, these strengths had not yet translated into consistent quality management.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was an open culture where staff felt able to speak up and raise any queries or concerns. Team members across houses told us they could approach management at any time and felt confident issues would be acted upon. One staff member said, “100%, I could speak to anyone with any concerns and would go straight to my line manager; they are good, they will support you.” Staff also described a supportive environment, where colleagues routinely shared information between houses. A duty of candour policy and procedure was in place, to support the aims of open and honest dialogue. A professional who worked with the service told us, “In my experience, the service demonstrates a commitment to transparency, good communication, and high-quality support for the individuals in their care.”

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. The service promoted an inclusive working environment where staff felt respected and valued. Staff received equality, diversity and inclusion training and felt the workplace culture supported them regardless of background or personal circumstances. One staff member explained, “They (management) have been supportive to me in all aspects”, including flexible working. Staff highlighted opportunities to voice ideas and improvements, telling us, “Management are pretty good. If we put things down on paper, they would give it a go.” While the culture was inclusive at team level, systemic workforce equality monitoring (for example, trends in recruitment, retention, or promotion in respect of equality and inclusion) was not in place due to gaps in governance systems. Strengthening this would help sustain the positive culture staff described.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance arrangements were not fully effective, and oversight systems were inconsistent. There were significant gaps in auditing across key areas, including recruitment files, care plans, daily notes, mealtime and quality of life monitoring. Where audits did take place, for example, medicines or environmental checks, they were often incomplete, unsigned, or missing action plans, limiting their effectiveness at identifying and reducing risk. Some audits had been archived during office building works and were not readily available. Essential statutory notifications had not been submitted to CQC as required. Although supportive visits took place, the provider had not carried out any formal audits or checks to show areas which needed attention, to support the newly registered manager. After the inspection, the provider confirmed they would introduce new supportive actions, including introducing cross-auditing between sister services, standardising oversight documents, and improving digital record implementation. These improvements were still at an early stage and not yet introduced or embedded.

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. While there were examples of positive relationships with social workers, health professionals, and community activity providers, input from relatives was not always well documented. For example, relatives told us they wanted more proactive updates and opportunities for involvement, as no formal relatives’ meetings were held. A relative said, “[Staff] are all fantastic, however we feel they could be better with communication on a more proactive level,” and, “The registered manager did some really good things and initiated lots, but I would like even more.” Although staff had meetings, there were no actions arising from minutes and they were not followed up to ensure any learning had been implemented, embedded and sustained. However, a professional who worked with the service told us, “I am always able to speak to a member of staff and management and find them very approachable when contacting them.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. The service did not have a fully embedded learning culture. The provider continued to financially invest in the service, with refurbishments, new electronic systems, and a new phone line. However, as there was no documented overarching provider-level strategy for the service, or any service development plan, the provider could not evidence how it sought to drive continuous improvement and innovation. There were no metrics for success, to monitor performance and to check if changes made had led to tangible improvements in people’s lives. This did not place the newly registered manager or the staff team in the best possible position to fulfil their roles. Despite this, staff and management were strongly committed to their work and sought to provide people with the best quality of life whilst also learning new systems and responsibilities. A staff member told us, “We are not perfect, we are still in the process of learning everything. We are on the right path.”