Hazel Garth

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
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 good governance.

This service scored 50 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.
The registered manager told us the local authority’s strategy for the service was under review and would focus on promoting people’s independence and supporting them to live safe, fulfilling and meaningful lives.
Staff spoke positively about the people they supported and demonstrated a commitment to providing person-centred care. They valued their role in supporting people and understood the importance of promoting their wellbeing. Comments from staff included, “We have a lovely set of residents, they all have different characters,” and “When the shift ends and the residents are happy, it is a great feeling.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.
Leaders and managers did not always demonstrate the skills, knowledge and oversight needed to provide effective leadership and drive improvements within the service.
Staff feedback indicated there were opportunities to strengthen communication and consistency within the management team. One staff member told us, “I wish they would sit and listen a bit more and wish they were on the same page, I don’t think they air their views with each other.”
Relatives shared mixed views about the management team. Some were unclear about who the managers were, while others provided more positive feedback. Comments included, “[Manager] is lovely, but I am not sure if they are saying what they think I want to hear, if it’s lip service or not,” and, “The manager is nice. I could talk to [them] if I needed to.”
We observed managers and leaders were visible within the service and regularly spent time in communal areas used by people. This enabled them to observe staff practice and interactions with people. Staff had access to training to support them in their roles, and training was either up to date or scheduled where refresher training was due.

People did not always feel they could speak up and that their voice would be heard.

Information was available for staff, people and relatives advising who they could contact if they had any concerns however, some staff felt unable to raise concerns openly or challenge decisions. Additionally, staff told us when they had raised concerns before, they had not been acted on or felt they had not been listened to.

At the time of the assessment senior leaders were holding engagement activities with staff to encourage staff feedback in line with freedom to speak up principles.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.
The provider employed a diverse workforce and promoted opportunities for people from a range of backgrounds and cultures to work within the service.
However, feedback from staff about teamwork and workplace culture was mixed. While some staff told us they felt they were treated fairly and with respect, others described inconsistencies in their experience. Some staff felt there was unequal treatment within the service and told us the registered manager had “favourite” members of staff and would only speak to staff “who they like.” This indicated staff did not always feel valued or supported equally in their roles.

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.
Systems and processes were in place to support oversight and drive quality improvement; however, these were not always operated effectively. Quality assurance and governance systems had not identified or addressed the concerns found during the assessment, including issues relating to record keeping, health monitoring and medicines management.
In addition, not all regulatory requirements were consistently met. For example, statutory notifications relating to safeguarding concerns had not always been submitted to CQC within required timescales. This meant we could not be assured governance systems were operating effectively to monitor the quality and safety of the service.

The provider told us they were implementing a new Quality Assurance Framework, but this was not sufficiently embedded to demonstrate improved governance.

We identified a breach of regulation relating to good governance. These issues had not been identified and acted upon through the service’s own quality assurance processes. The provider has taken action to address the concerns raised since our assessment.

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.
Opportunities for people to access community activities and participate in local events were limited. There was no evidence of a planned or proactive approach to developing links with the local community or building partnerships that could support people to remain connected with their wider community.Following the assessment the provider told us of plans they have in place to improve the links with communities.
External professionals, including district nurses, GPs and social workers, visited the service regularly. They told us communication was effective, relevant information was shared appropriately, and staff followed professional advice and guidance.
However, governance systems were not always effective in identifying and monitoring changes in people’s health needs. As a result, some concerns had not been recognised by the provider and therefore could not be escalated or shared with partner agencies when required. This increased the risk that people may not receive timely support to achieve positive health outcomes.

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.
The provider had an improvement plan in place, and progress against actions was monitored and recorded. However, the effectiveness of this oversight was limited, as some actions had been marked as completed despite ongoing concerns remaining within the service.
For example, the improvement plan identified the need to implement a dependency tool to assess staffing requirements. Although this action had been recorded as completed in June, managers had not effectively used the findings of the tool to identify and address concerns about staffing levels at key times of the day. This meant the service had not fully considered whether enough staff were deployed to meet people’s needs.
The improvement plan also identified actions to strengthen oversight of medicines management and care records, including increasing medicines audits and undertaking spot checks of records relating to people’s nutrition and fluid intake. While these actions were underway, governance systems had not identified the concerns we found during the assessment.
Our assessment identified a breach of regulation relating to good governance. This demonstrated that leadership and governance arrangements had not been effective in identifying risks, learning from concerns, and driving sustainable improvements within the service.