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.

At our last assessment we rated this key question inadequate. 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 the good governance of the service.

This service scored 43 (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 fully understand the challenges and the needs of people and their communities.

Communication within the service was inconsistent. Staff reported not always being informed of changes to people's care needs or organisational updates, increasing the risk of inconsistent care delivery.

There was a lack of effective oversight from management, and concerns identified through audits, complaints and feedback had not always been addressed in a timely manner.

Communication was poor, and staff were not always aware of changes affecting people's care., for instance, inconsistencies across staff regarding a person’s bed rails.

There was limited evidence of learning, reflection or staff involvement in service development. Management oversight was ineffective, and identified concerns had not been addressed promptly. This resulted in a culture that did not support continuous improvement or empower staff to provide the best possible care.

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. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Although the management team were visible and approachable throughout our assessment 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.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The service promoted an open and positive culture where staff felt able to raise concerns. Staff were aware of the processes available to speak up and told us they felt confident to report concerns relating to safety, quality of care, and workplace practices. They were assured concerns would be listened to and acted upon appropriately. However, we were not assured that all reportable concerns with the safety of the environment where being reported we saw no evidence of this. Lessons learned from incidents were limited but some were being shared in team meetings.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they felt supported and were confident the registered manager and provider promoted inclusion and equity. Staff could give examples of how their individuality was recognised and their rights upheld. One staff member shared how their working pattern had been changed due to other commitments

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.

Governance systems were ineffective and did not provide leaders with adequate oversight of the service. Quality assurance processes failed to identify and address risks, resulting in missed opportunities to improve care and support.

Care plans were not always up to date and did not consistently contain the information required to ensure people received safe and person-centred care. Audits lacked sufficient detail and failed to identify or drive action in response to known concerns, limiting the provider's ability to monitor quality and improve outcomes.

Leaders could not demonstrate sufficient oversight to ensure safe, high-quality, and sustainable service delivery. The provider was unable to evidence a clear approach to managing risks or driving continuous improvement.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always act on advice from partners to ensure collaborative working.

The service worked with external professionals and partner organisations to support people's care; however, these arrangements were not always consistent or well-coordinated. While some positive relationships had been established, the provider could not always demonstrate effective collaboration to improve outcomes for people using the service.

Feedback from partners was not always positive with one saying, “I have to wait for prolonged times to enter the building which puts pressure on my workload.” Advice from other professionals was not always acted upon. A health professional had advised to stop using equipment to aid a person’s independence. This was not acted upon.

Leaders recognised the need to strengthen partnership working and community engagement to ensure people benefit from coordinated care and wider opportunities, for instance activities, within their local community.

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 did not have effective systems to support learning and improvement. Audits lacked detail and failed to identify concerns, including care plans that were not always up to date. As a result, opportunities to improve care were missed.

Staff were not consistently able to describe how learning from incidents, complaints, or feedback was shared across the service. A relative said, “I’ve raised concerns before, but I don’t know what happened afterwards.”

The provider could not demonstrate a culture of continuous improvement or how innovation was used to improve outcomes for people. In addition, the provider had failed to demonstrate sufficient learning and improvements had been made from our last assessment to meet all required regulations.