Norden 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 newly registered service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.
The providers recruitment policy, aligned with the Equality Act 2010, which ensures fair opportunities for all candidates, who were then supported by a robust equality and diversity policy in the workplace.
Staff described the team as having an open culture in which they could raise issues, who received training around equality and diversity. We observed staff speaking and interacting with people and each other in a friendly respectful manner. A staff member commented, “The interim manager is approachable, and the senior staff support us when we need them, if something is wrong, we can openly talk about it.” Meetings for people were held to gain their views and provide an opportunity to give feedback.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

At the time of our assessment there was no registered manager in place, however the provider was in the process of recruiting for the role alongside other leadership roles. An interim manager was supporting the team whilst this process was taking place. Staff told us they were being supported by the interim manager, and another staff members role was adjusted to provide further support until suitable candidates for the leadership roles were found.
During our assessment we observed staff at all levels supporting people compassionately.
The providers values were clearly displayed and communicated to staff who reflected them in the support they provided. For example, a senior staff member describing their experience said, “I have received training for my role and been supported by the manager, they listen if I give them feedback.”
 

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

Staff were encouraged to speak up through an open culture and a clear whistleblowing policy, with reporting procedures introduced during their initial induction. A staff member said, “If I had a concern, I would tell the manager and I’m confident they would listen.” The service had a freedom to speak up champion in place, whose role was to support staff to speak up should they feel, they cannot access the usual routes to do so.

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.

A culturally diverse staff team had been recruited. Staff said they were proud to work with people from different backgrounds and felt they were valued and respected in their roles. A staff member said, “We have a mixed culture here, we work together and respect each other’s differences.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
The provider had quality assurance systems in place however these had not always been effective in ensuring information was accurate and reflected people’s current needs. For example, a person’s Speech and Language Therapy guidance (SALT), which supports them around lowering the risk of choking and has different levels depending on a person’s needs, had the incorrect level detailed in their care plan. The providers quality assurance systems had not identified this, which had the potential to cause the person harm however, staff who prepared food and drink alongside providing support were aware of people’s needs including their correct SALT guidelines.

Trends around incidents were not always being identified and followed up to reduce the associated risks. There had been 17 medication errors in a one-month period that had not been reviewed effectively to reduce the risks. The interim manager had created an action plan highlighting this issue and was in the process of addressing it at the time of our assessment.
Audits of the call bell system had not identified shortfalls in its use including staff understanding of this system resulting in people having to wait to be supported potentially putting them at higher risk of falls. We raised this concern with senior management who arranged an audit of the call bell system to investigate why staff were not always being alerted when people utilized it. The provider responded to shortfalls around governance robustly, utilising additionaloversight and support from other internal resources to improve these areas which require embedding in practice.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, they did not always share information and learning with partners.

Professionals who worked with the service we spoke with told us about barriers they had faced, when trying to communicate with staff about people’s health needs. One professional said, “There have been delays in the staff responses and answering important emails or sometimes not replied to at all, the consequences of these delays can affect medication reviews and prescribing.” We identified occasions where advice and instructions around medication changes had not been updated promptly in a person’s care records.
The interim manager had responded to concerns professionals raised to improve people’s outcomes by addressing communication issues between services which need to be embedded. A professional said when describing the interim manager “Our experience of the new management has been positive as they are addressing our concerns as we raise them.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The interim manager had created an action plan to improve people’s experience and outcomes. Following feedback around the challenges of supporting people’s different needs in mixed areas, the service was divided into need specific units to provide focused support.
Staff were encouraged to progress in their roles with opportunities available. One staff member said, “I have the chance take on other roles and when I am ready, I believe they will support me.” Senior management had a positive attitude towards learning and shared information across the providers services. For example, raising awareness around submitting statutory notifications when needed.