Abode

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.

This is the first assessment for this service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in service 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 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.

Various health professionals have shared that the culture at the service is challenging and is not necessarily one that fosters a collaborative working environment, that works towards meeting the needs of people. As feedback from professionals, conversations with management and our observations and records we reviewed did not align, it was difficult to ascertain transparency.

Staff spoke about the visions and values of the service. One staff member said, the vision and values were "to give support to people." Though we found this was not always happening as detailed throughout this report.

Although the management team were visible and approachable throughout our inspection and staff spoke positively of the management, due to the concerns we have identified, we found appropriate care was not always being delivered. The management structure had not identified many of the issues we have found throughout this report, for example we found multiple audits scored at 100% in areas where we identified issues.

Staff were not always able to explain what whistleblowing was, but we are not sure if this was in part due to language barriers. The provider had a whistleblowing policy available to staff, however this needed to be updated with correct information as it referenced a care home that is not associated with this service. Staff were able to raise any concerns in team meetings.

Various policies were in place to support an open culture, and the registered manager told us they have an open-door policy.

Staff told us they were treated equally and fairly in a compassionate way. The service employed a diverse range of staff. Staff told us they felt supported in their role and that the management were approachable and fair to staff. An equality and diversity policy was in place which set out how the service supports equality and diversity.

Although multiple audits and oversight tools were in place they did always not identify the issues we found during our inspection. An audit relating to the sluice referenced a sluice machine which was not in place in the service. The service had CCTV in place throughout communal areas. Appropriate updated records relating to registration with the information commissioner’s office was not in place during our inspection, however this was updated following our site visit by the provider. Some records were not up to date. For example, various policies required reviewing and updating. The statement of purpose we were provided with did not detail accurate information. Following the inspection the provider sent us an updated copy. People’s personal records were not always being securely stored. Provider oversight was not robust.

There were 2 cupboards that contained people’s personal records which were not locked. Some people’s records did not always appear to be appropriately or accurately completed or a detailed as they should have been (as mentioned in this report) and audits failed to identify this. Some people living at the service were living with a learning disability which was their primary care need, and the service does not have appropriate registration in place to support this type of care being provided. Staff told us they felt the management had oversight of the service, though we found this not to be the case. The provider told us they would work to improve oversight, records storage and audits following our inspection.

Although we did see some examples of the service working with various organisations, it was apparent that some professional relationships had become fractured. Feedback from partners was not always positive. One professional told us, “I think it can be a barrier sometimes, they don’t always want to ask for help.”

Although people’s relatives generally felt they were kept up to date and people could gain access to support when needed, partnership working collaboration was not as seamless as outlined above.

Although staff felt lesson learned was shared with them following incidents, the service did not focus on continuous learning and improvement across the organisation. This is because audits were not identifying the issues we found which made it difficult to understand how the service was identifying concerns relating to both the care people received and environmental concerns and how they learned and acted upon them. They did not consistently and actively identify and contribute to safe, effective practice as covered throughout this report. Some professionals spoke of problems where the service was quick to blame professionals, which could be seen as a blame culture rather than a learning culture.