South Street

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 the service under this provider. This key question has been rated 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 governance at the service.

This service scored 61 (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 equality, human rights and diversity.

We viewed an equality and diversity policy and found most staff were equality and diversity trained. Staff told us they promoted people’s human rights by ensuring their individual rights, needs and preferences were documented, understood and promoted by the service. For example, staff said, “It’s all about them [people]. We simply do whatever we can to respect how they want to live their lives.”

Staff also told us how the vision and culture of the service had changed since the recent provider change., For example, 1 staff member explained, “The provider wants to do all it can to support us [staff] to be able to support people as best we can. Things have improved since the new provider has taken over – we can now do more things.”

The provider told us about the positive culture and vision of the service for the people they supported. This included ensuring the people they supported having a safe and meaningful life which respected their human rights.

We viewed staff meeting records which showed leaders discussed standards and goals with the staff team to promote collective awareness and understanding. This included discussions about how the service can ensure people’s needs are being met and how staff can achieve this.

Leaders did not always demonstrate the skills and knowledge to lead aspects of the service effectively.

While feedback from staff was that leaders were positive, compassionate and inclusive, leaders had mostly not identified the concerns we have referenced under the safe section of our report, which included incident management, environmental risks, IPC risks and medicines management, which meant the service was not always being managed effectively at the time of the inspection. This meant there was an increased risk to people living at the service.

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

We saw there was a culture of speaking up. The provider told us staff were aware of the importance of raising concerns and understood the process, which is discussed with staff within team meetings and supervisions.

Staff told us they had not needed to raise concerns, but that they were aware of how they should do so and they were confident the manager would take concerns seriously, with 1 staff member saying, “I haven’t had to raise concerns, but if I did, I’m confident it would be dealt with.”

Team meeting records were viewed which showed leaders discussed with staff their expectations and what they should do should they ever feel they have concerns about people’s care.

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

The provider informed us they valued a diverse workforce and treated staff fairly. Staff supported this by telling us they were happy working with the provider and felt they were treated fairly. There were processes in place to consider staff member’s individual needs, such as regular supervisions and team meetings.

Effective governance systems were not in place to ensure safety and quality concerns were identified and acted upon.

Risks at the service had not always been identified and acted upon to promote safety. For example, we found effective systems were not always in place to ensure: the appropriate review and learning from accidents and incidents; the identification and mitigation of people’s behaviours, environmental, staff training and IPC risks; daily medicines being administered as prescribed; topical medicines guidance being in place and ‘as required’ medicines guidance being in place. We found where there were known issues, action had not been taken in a timely manner to rectify concerns and drive service improvement. For example, issues relating to fire safety despite being known had not been addressed prior to our inspection.

This meant governance systems were not effective and exposed people to the risk of harm.

The provider understood their duty to collaborate and work in partnership in order that services could support people.

Staff and the provider were aware of which partners and stakeholders were available to the service and how to access this support. The provider supported people to integrate within the wider community to improve their social, health and emotional outcomes, and we saw people were supported to access a wide range of local settings and provisions.

The provider did not focus on continuous learning and improvement across the service.

Leaders did not always have a good awareness and understanding of audit processes and how these can be used to effectively to identify concerns and mitigate risks to achieve continuous learning and improvement.

As a result, leaders had not identified areas of the service which required improvement, such as those we identified during our inspection. This meant there were missed opportunities to learn and make improvements to the overall quality and safety of the service.