Archived: Nerissa 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.

This is the first assessment for this service. This key question has been rated 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 regulations relating to good governance and staffing.

There was a poor culture at the service. Staff were not consistently supported to develop their knowledge and understanding of people’s needs, to discuss a shared vision or to improve people's lived experiences. Staff did not have sufficient information within people’s care plans to enable them to provide safe and appropriate care and support. The service was not being managed well, and the lack of governance systems in place meant the service was not effective. Lack of auditing and reviews by management failed to recognise shortfalls in people’s care and the service. Governance arrangements were not effective, including oversight and management of risk and maintenance of the premises and equipment.

This service scored 25 (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 identified a lack of transparency and openness in relation to the reporting and escalation of incidents and concerns to external stakeholders including the local authority and CQC. This did not protect people from the risk of harm or uphold their human rights and protected characteristics.

Information which would have contributed to more positive and collaborative outcomes for people using the service was not included in the individual’s support plans or the aims and objectives of the service. The service had not completed any quality, safety or environmental audits.

Some staff demonstrated a lack of understanding in relation to the needs and abilities of people living at the service.

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.

We identified significant failings in the lack of oversight of the service by the provider. Directors did not ensure they had clear oversight of the service and awareness of risk and concerns arising from the service, impacting on the safety, quality and standards of care provided.

Leaders of the service did not have the relevant experience and knowledge to lead the service. There had been no registered manager in post for a number of months. The provider and managers were not aware of current legal requirements in regard to health and safety, including those related to fire safety, use of window restrictors and safe storage of medication.

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

The service was at increased risk of developing a closed culture, due to information not being reported externally. We identified concerns relating to the performance and judgement of certain staff and leaders in relation to the handling of concerns and incidents and found these had not been dealt with openly and transparently. Staff told us on the occasions they had raised concerns that the provider had failed to listen.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us there had been several managers over the past year. They also told us they worked very long hours.

There was no evidence of promotion of workforce wellbeing at the service. There had not been staff meetings, supervisions and appraisals. There was no evidence of staff surveys and where staff had provided the management with feedback, this was not actioned.

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 distinct lack of governance systems and processes in place. Leaders demonstrated a lack of understanding of their regulatory responsibilities in relation to reporting to external stakeholders.

There had been significant failings relating to the care environment which the provider was not aware of, including a lack safety checks and actions in response to external fire and electrical surveys.

The provider had failed to safeguard people by poor staff management, including lack of staff training and supervision.

The was a lack of clear risk management in support plans and where restraint had been used this was not clearly and accurately documented, to facilitate effective monitoring and oversight of this. The provider had failed to consistently safeguard people’s personal data by the inappropriate sharing of people’s care notes with the wrong family members.

There was no business continuity plan to ensure that the service could operate safely in emergency situations.

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.

We identified concerns regarding relationships and communication between the service and commissioning bodies. A lack of effective reporting and escalation to the local authority did not ensure external professionals were fully aware of the level of risk and concern arising within the service. Referrals were not made to other agencies to support people, such as advocacy and appointeeship services.

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 systems in place to monitor the effectiveness of the service including, staff feedback, partnership and family feedback.

There were no lessons learnt following incidents and accidents and no learning shared for improved practice in the future. There was no quality assurance or action plan to identify and enable future development and improvements for the service.