Coralyn House

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 continued to be in breach of legal regulation in relation to good 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. We found a mixed picture regarding the service’s culture and future direction. We found some of these areas and practices were not always recognised and fully embedded.

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 were not assured leaders had the skills or knowledge to lead effectively and they did not do so with integrity, openness and honesty. The service had not sustained any significant improvement, and people did not receive safe care and treatment. At our previous inspection we raised to the provider that they had not implemented a robust system to maintain their own oversight of the quality of the service. The provider has failed again to implement a robust system, therefore putting people at continued risk of harm.

The service had not sustained any significant improvement, and people did not receive safe care and treatment. Although we raised at our previous inspection the provider had not implemented a robust system to maintain their own oversight of the quality of the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they knew how to raise a concern and felt they could raise concerns to the provider. One staff member said, “The provider is very supportive if I need anything.”

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. There were some systems in place, such as an Equality, Diversity and Inclusion policy, however we found there were not always effective systems in place to best support the service or the staff. Therefore, this had an impact on the well-being of the staff.

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. There was a complete lack of responsibility by the provider in managing risks to people, and this potentially could have significantly impacted people’s quality of life and their safety. We saw audits were in place by the provider however these were not effective in driving improvements. The shortfalls we identified at this assessment were not rectified in a timely manner and governance systems in place had failed to identify these.

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. There was a lack of engagement into the local community to engage and support peoples emotional and spiritual needs. The service did not ensure the accuracy of information shared with others involved in people’s care. For example, in relation to mobility and eating and drinking needs.

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. At our last inspection we identified breaches in relation to safe care and treatment, good governance and fit and proper persons employed. At this inspection we found repeated breaches of safe care and treatment and good governance. The provider failed to ensure that improvements from the last inspection had been addressed to comply with legal regulations.