Archived: 142 Petts Hill Care 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 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 inadequate. At his assessment the rating has remained 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.

We found the provider was in breach of legal regulations in relation to the governance of 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.

Staff could not support the vision, values and strategic goals of the service and how their role helped in achieving them because the provider did not have one in place. There was no focus on learning and improving, the provider had not sought feedback from the people who used the service, staff or external partners; therefore, they did not understand the challenges and the needs of people and their communities. Staff did not receive regular supervision or appraisals and there were no team meetings in place. Equality, diversity and human rights were not actively promoted. The provider could not evidence that they had a legal basis to control and restrain people and that it was necessary and proportionate to the risks concerned. There were no best interest meetings in place for people, or consent sought.

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.

We identified serious breaches of regulations which placed people at risk of harm. Leaders were not able to demonstrate consistent knowledge of their legal responsibilities or providing a safe and good quality service.

Quality assurance systems and processes were not operated effectively, and there was a failure to identify and address areas requiring improvement. Managerial oversight of the service was lacking, and the registered manager failed to identify and share learning from accidents and incidents to prevent them happening again. This placed people at continued risk of avoidable harm.

The provider could not evidence that they had systems for speaking up. There was no evidence of engagement with people and their representatives, and no strong focus on supporting people to thrive, develop skills, have new experiences and live the life they choose. There were no open forums for example team meetings and supervisions for staff to participate and contribute to the running of the service. However, people and staff felt they could speak up and that their voice would be heard.

The provider could not evidence that they had procedures to help ensure the workforce were fairly treated and there was no discrimination. However, staff said they felt supported and could discuss their concerns with managers.

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.

Governance systems and processes failed to identify, monitor and drive improvement in the quality and safety of services provided, including the quality of the experience for people using the service. These systems also failed to mitigate any risks relating to health, safety and welfare of the people who used to service. Issues related to medicines storage, food safety and infection control and prevention which had not been picked up by governance processes and consequently no action had been taken to address these issues. We were not assured that staff could perform their roles safely and effectively as we did not have sight of a training matrix, staff competencies or supervision notes. Furthermore, we were not assured that people were receiving appropriate care and treatment due to the lack of this evidence and concerns around the lack of sufficient staffing levels to meet the needs of the service. We requested evidence of the providers’ training matrix but did not receive this, despite reminders. This meant that we were not assured staff had the training and support to ensure they could carry out their roles effectively. The provider failed to follow the concerns up such as notifying the Care Quality Commission (CQC). The impact of this was the person missed his medicine as prescribed.

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 management team did not always promote working with health professionals and ensure people received support following guidance.

The provider did not focus on continuous learning, innovation and improvement across the service. 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. There were no effective processes in place to identify and share learning across the service in respect of accident and incidents, best practice, and required improvements. Staff and management meetings did not take place regularly to promote learning, improvement and innovation. The registered manager was not proactive in ensuring evidence-based practice was embedded within service delivery. The service audits in place were dated 2021 and 2022, we were told there were more recent ones however these were not sent to us, despite reminders. The provider’s oversight was ineffective and failed to identify shortfalls found at this assessment. The service had a history of non-compliance; we inspected the service on 21 March 2023. Following this inspection reports were issued identifying failures to comply with Regulations. A condition was placed on the provider to complete an action plan and send it to us on a monthly basis. The provider failed to achieve compliance therefore failing to respond adequately to serious concerns raised by CQC in order to improve the safety and quality of service provision.