Saxondale Nursing 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 requites improvement. 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 continued breach of the legal regulation in relation to the governance of the service.

This service scored 36 (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. At the last inspection we found inconsistencies in leadership and governance had led to shortfalls at the service. At this assessment, the provider confirmed, and we found inconsistencies in leadership and governance continued to be an issue, resulting in ongoing shortfalls within the service.

Not all leaders 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. The quality monitoring visits conducted by senior management proved ineffective in promptly identifying issues. The provider's service review revealed the management team had not consistently demonstrated transparency and openness in their communications and actions. Leadership at the service had failed to ensure there was a positive culture at the service that was open and person-centred. The service was in the process of recruiting new people into the management structure after a period of managerial instability, any improvements from this will take time to embed.

People did not always feel they could speak up and that their voice would be heard. Policies and procedures were in place and available to staff about how to whistle blow on poor practice. Staff told us they did feel comfortable approaching managers however they did not feel that their concerns or suggestions were listened to or acted upon.

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. We found this out because many staff members told us they didn't even know who their manager was. One staff member commented, “I don’t know who the manager is, it was [Name] and then [another name] but I don’t know it is now. Theres been so many changes in the 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. At the last inspection we found audit processes were either not operated effectively or not established. At this assessment we found systems and processes had not sufficiently improved. The provider was open and honest with us throughout the inspection. They had recognised improvements were required and had started to address these. Governance systems were ineffective in identifying concerns we found in relation to safeguarding, risk management, and person-centred care. A new manager had been appointed. New audits were being introduced to monitor the quality and safety of care people receive, these required embedding into practice at the time of our inspection. Whilst the new management team was taking steps to improve the service, overarching governance systems were ineffective.

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. Improvements were required to provide people with community engagement and meaningful activities. We received negative feedback from partners who worked with the service about the safety and quality of the service. They told us there were various actions which required completion, this was also found by us during our inspection. Throughout the inspection the management team were honest and open with us. They acknowledged the shortfalls identified at this inspection and were eager to put processes in place to ensure people receiving care and support were safe and protected from harm.

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. During our inspection the provider was open and honest with us about the improvements which were required. They had recognised the concerns we identified and had formulated various new systems and action plans. These required a period of time to be completed and embedded into practice.