The Coach House SBDP1 Limited

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 remained the same. 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 governance at the service.

This service scored 46 (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 had a clear vision strategy and development plan for the service which set strategic development priorities for 2024-2027. They also developed clear values to be embedded in their practice. However, the findings from this assessment showed the priorities had largely not been delivered against. The provider reviewed the progress of the equality, inclusion and diversity and reported on the initiatives which have been introduced. Whilst there are some positive developments in this priority for staff, there could be more focus on how this priority can improve outcomes for people using the service.

The provider and management team were a visible presence in the service. However, staff did not always feel supported in their roles and told us they were not always given enough time to complete the role expected of them. However, staff told us how supportive the provider was when they experienced personal difficulties and they would arrange their working hours around personal obligations to ensure a good work-life balance where they could.

People did not always feel they could speak up and that their voice would be heard. Staff told us they have raised concerns multiple times and have not felt listened to. For example, staff have told us they have raised concerns about there not being enough staff.

The provider valued diversity in their workforce. The provider viewed workforce equality, diversity and inclusion as a priority and had implemented a number of initiatives to promote this within the service. The staff team at the service was multi-cultural, and the provider placed great emphasis on embedding cohesive working.

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. The governance processes used by the provider did not identify shortfalls within the service, and therefore, could not drive improvements. For example, audits of people’s care records failed to identify the concerns we found as part of this assessment. We also found there was no overarching audit for medicines.

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 provider failed to share information with us about specific incidents, which they are required to by law. We also saw they did not notify the local authority of all safeguarding incidents. However, the provider reported they had fostered good working relationships with professionals such as social workers and specialist community teams.

The provider told us they were active members of provider forums where they could share learning. They had also worked closely with their training provider and the local authority to deliver communication training, focusing on examples taken from the service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. Whilst the provider had identified priorities to address, little progress had been made. At our last inspection in 2019, we rated the service as requires improvement for similar issues found as part of this assessment. This does not demonstrate a culture of learning or improvement.

The provider had made some improvements in the area of equality, inclusion and diversity and had implemented regular events and initiatives welcomed by people who use the service and staff. This included a ‘bring a dish’ gatherings to celebrate different cultural celebrations.