Archived: Iceni 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to 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 regulation in relation to governance at 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.

The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. We found evidence of a closed culture within the service. When we asked staff if they felt there was a culture of collaboration within the service we were told, “I do not have a good relationship with my senior as they have a friendship group and look after each other.”, “I do not want to rock the boat.” And “There is not a lead by example culture.” We asked staff if they were aware of the visions and the values of the service and they could not tell us what they were. However, the new management team were aware of this organisational culture and were working with the staff to improve it.

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. The previous registered manager and nominated individual had left the service in August 2025 and the provider had no oversight to ensure the environment was being maintained and managed appropriately. New management came into the service and quickly identified the shortfalls. The management team had begun to implement systems and processes, but these were not embedded, and we were not assured on the oversight provided long term to ensure these situations would not arise again. There was no registered manager in the service, although the management team had recruited unit managers and a night manager to oversee the service with their support and they were actively recruiting to fill the registered person status.

People did not always feel they could speak up and that their voice would be heard. The service had a freedom to speak up policy in place, but this recorded the freedom to speak up guardian as the previous nominated individual and had not been updated. Staff confirmed no regular staff surveys had been carried out. We received mixed feedback from staff around freedom to speak up, 1 staff member said, “I do not feel staff can speak up, I cannot as I am worried for my job, I do not want to lose my job.” And “Maybe speak up but worry about the outcome.” Other staff told us “I go straight to [interim manager],” and “I feel that I can go to [interim manager] and also raise any concerns daily during briefings.”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider had an equality, diversity and inclusion policy in place. We were not assured staff wellbeing was actively being monitored due to a lack of supervisions and oversight. We asked staff about how staff are treated we were informed “needs better communication for everyone, not just 10 at 10 meetings” We were informed staff can input flexible working requests and these are reviewed, 1 staff member told us “[interim manager] supported my flexible working request.” The new management team had begun to work on the workforce equality within the team, and this was being noted by staff. 1 staff member told us “I feel that the management care. [unit manager], [nominated individual] and [interim manager] have all been kind.

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. The provider had a lack of systems in place that prevented them from having good quality assurance and management oversight. There was a lack of spot checks conducted on the staff and this has contributed to the closed culture within the environment. There was a lack of clear oversight day to day in the service. Where issues were identified they were not always acted upon and lacked in defining what was required, who would complete it and within what time frame. We received mixed feedback from staff, “I do not think the home is well managed, it has always had an unstable management team. Management is better now than before.” The management team had looked at their systems and had begun to implement new processes, but they were not embedded at the time of our assessment.

The provider did not ensure that people had access to the local community and did not always work well with partners and share information. People were not actively supported to access the community when the providers policies reflected the importance of it unless it was for a medical appointment. We reviewed peoples care records and there was no evidence of people accessing the community. This was echoed by people and relatives. 1 person told us “I tell them I like going outside but I do not see anyone.” And a relative told us “I’m the only one who takes him out in his wheelchair. I don’t think anyone else does there”. When we asked staff how people are supported to integrate with the wider community a staff member told us “I have not yet seen anyone go out into the community.” Although the service had begun to improve on the working relationship with partners, the provider had not previously ensured there was adequate oversight in place to ensure partnership working remained consistent.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. The provider did not have adequate quality assurance systems in place. They could not evidence that staff were encouraged to speak up about new ideas or reflect on areas of improvement. Staff did not feel they were asked to put ideas forward. The new management team had planned to implement a lot since being in the service, but it was not embedded, and we were unable to assess the effectiveness of it.