Aspire Hub 1

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 46 (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. Some staff told us the culture of the service needed to be improved. Comments included, “We’ve had a few managers recently. The new manager hasn’t been around much to meet staff and the people” and “The registered manager doesn’t like the staff that challenge.”

Policies and procedures were in place to guide staff in equality, diversity and human rights. Staff had completed their equality, diversion and inclusion training.

During our assessment, the provider showed evidence of how they had tried to promote and improve the culture including team meetings. Various policies were in place to support an open culture, and the registered manager told us, "The service had different groups that discusses issues relating to Equality, Diversity and Inclusion.”

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Incidents and accidents were recorded; however, actions were not always followed up. For example, there were incidents where the provider had recorded “incident to be discussed in staff meetings and staff supervisions”. We reviewed meeting minutes and supervision records, and this had not always been done. One staff member had made 5 medication errors within 12 months, and their supervision record advised further training was required however, this training did not occur therefore lessons were not learnt.

Oversight to identify trends and themes was not robust. In some instances, records did not include the staff member’s name who was involved in the incident and the date the incidents happened to identify common themes.

Some staff told us they were not informed of actions taken when they had reported incidents. Comments included, “We report concerns to management about neglect of people, and they don’t do anything. They hardly ever feedback about incidents or trends” and “We don’t hear back about incidents we report. We fill out a form and give it to management and they take over. I don’t know what happens after that.” One relative stated, “I report things they don’t address them.”

People did not always feel they could speak up and that their voice would be heard. Staff told us they had shared concerns with the service; however, these were not acted upon. Relatives told us they felt able to share concerns with the service.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Incidents and accidents were recorded; however, actions were not always followed up. For example, there were incidents where the provider had recorded “incident to be discussed in staff meetings and staff supervisions”. We reviewed meeting minutes and supervision records, and this had not always been done. One staff member had made 5 medication errors within 12 months, and their supervision record advised further training was required however, this training did not occur therefore lessons were not learnt.

Oversight to identify trends and themes was not robust. In some instances, records did not include the staff member’s name who was involved in the incident and the date the incidents happened to identify common themes.

Some staff told us they were not informed of actions taken when they had reported incidents. Comments included, “We report concerns to management about neglect of people, and they don’t do anything. They hardly ever feedback about incidents or trends” and “We don’t hear back about incidents we report. We fill out a form and give it to management and they take over. I don’t know what happens after that.” One relative stated, “I report things they don’t address them.”

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Incidents and accidents were recorded; however, actions were not always followed up. For example, there were incidents where the provider had recorded “incident to be discussed in staff meetings and staff supervisions”. We reviewed meeting minutes and supervision records, and this had not always been done. One staff member had made 5 medication errors within 12 months, and their supervision record advised further training was required however, this training did not occur therefore lessons were not learnt.

Oversight to identify trends and themes was not robust. In some instances, records did not include the staff member’s name who was involved in the incident and the date the incidents happened to identify common themes.

Some staff told us they were not informed of actions taken when they had reported incidents. Comments included, “We report concerns to management about neglect of people, and they don’t do anything. They hardly ever feedback about incidents or trends” and “We don’t hear back about incidents we report. We fill out a form and give it to management and they take over. I don’t know what happens after that.” One relative stated, “I report things they don’t address them.”

The service 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 management had developed good links and worked closely with health professionals.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Incidents and accidents were recorded; however, actions were not always followed up. For example, there were incidents where the provider had recorded “incident to be discussed in staff meetings and staff supervisions”. We reviewed meeting minutes and supervision records, and this had not always been done. One staff member had made 5 medication errors within 12 months, and their supervision record advised further training was required however, this training did not occur therefore lessons were not learnt.

Oversight to identify trends and themes was not robust. In some instances, records did not include the staff member’s name who was involved in the incident and the date the incidents happened to identify common themes.

Some staff told us they were not informed of actions taken when they had reported incidents. Comments included, “We report concerns to management about neglect of people, and they don’t do anything. They hardly ever feedback about incidents or trends” and “We don’t hear back about incidents we report. We fill out a form and give it to management and they take over. I don’t know what happens after that.” One relative stated, “I report things they don’t address them.”