Summerfield Court

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 requires 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 breach of legal regulation in relation to governance.

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.

The findings from our assessment indicated the culture of the home was not person-centred. We founda disconnect between the stated purpose of the service and the care being delivered. Many people had lived at the service for extended periods, with limited evidence of rehabilitation or progression towards greater independence. Managers acknowledged that the service was not operating as an active rehabilitation service but staff, people and records did not consistently reflect a shared understanding of this model or how it translated into care.

We found warning signs of a closed culture developing at the service. CQC defines a closed culture as being as 'a poor culture that can lead to harm, including human rights breaches such as abuse'. In these services, people are more likely to be at risk of deliberate or unintentional harm. Some examples of signs found during this inspection included inconsistent application of the MCA, restrictive practices that were not always clearly justified or reviewed and limited focus on positive outcomes for people.

The service did not have consistent, capable leadership in place. There was no registered manager at the time of inspection, and the service had experienced repeated management changes, with several interim and short‑term arrangements.

Although senior leaders were visible during our assessment, and engaged constructively with the process, leadership had not been effective in addressing known risks or embedding sustained improvements. [WB1]Several issues identified during this assessment, including concerns about restrictions, MCA/DoLS and people’s finances, had been previously identified by the provider, but had not been acted on in a timely or effective way.

The management team were not able to consistently demonstrate that decisions about care, restrictions or service direction were well understood, clearly documented or reviewed, limiting trust in leadership capability and inclusivity. The lack of effective and consistent management oversight placed people at risk of not receiving the care they required.

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

Some staff told us they felt they were able to speak up, however they could not always describe us how to follow whistleblowing procedures.

Feedback from people was sought through and surveys. Records reviewed showed people had made comments around areas for improvements. However, there was limited evidence of how this feedback had been used to improve the service or review people’s care arrangements.

The provider had an equality and diversity policy in place. Staff told us they enjoyed working at the service.

Our findings highlighted gaps in inclusive practice, particularly around communication and decision‑making. Feedback from professionals also raised concerns that reasonable adjustments for communication were not consistently embedded, particularly in capacity assessments and care planning. As such, equality and inclusion were not consistently promoted or assured across all aspects of care.

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.

We found widespread failings in the management and oversight of the service, which meant people did not always receive person centred care. We found the management oversight of essential areas of delivery of care had not always been robust or effective.

There were various quality assurance systems in place. These included audits on care notes, care plans, medication, finances. However, these had not been effective either in identifying some of the issues we found during this inspection or in taking timely action to act on known concerns and address them. There was an improvement plan in place where areas for improvement had been identified. However, we continued to find the same areas of concern and examples of lack of timely action, such as management of finances and DoLS.

Care plans and records of care were not always complete, accurate and contemporaneous.

Feedback received from people, relatives, healthcare professionals and staff was mixed about the management team.

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.

The service had established links with external partners, including healthcare professionals and commissioners. However, partnership working was not always consistent.

Feedback from professionals highlighted poor coordination and follow‑up, particularly around therapy input and multidisciplinary working. Managers were not always acting as an effective central liaison point, resulting in delays or missed opportunities to improve 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.

The service did not show a strong culture of learning or improvement. Several issues identified during this inspection, such as lack of person‑centred care, ineffective oversight of restrictions and gaps in record‑keeping, had been found before but were not resolved. This meant the service was not able to sustain improvements or drive innovation.

We identified several breaches of the relevant regulations, which indicated the provider had not sufficiently focused on and enabled continuous learning and improvement.