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. 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. The provider had a vision for the service which they shared with us; however, this vision was not embedded into daily practice. For example, the vision described the service as consistent, compassionate, person-centred and promoting quality of life. However, the evidence from this inspection found people received inconsistent care which was not in line with their individual preferences which impacted on their quality of life. The vision also described giving everyone opportunities to enjoy their life and pursue meaningful activities and achieve personal goals. However, we found people had limited opportunities to do the things they enjoyed as staffing levels were insufficient to enable people to pursue their individual interests and achieve person-centred outcomes. This meant people did not have their needs consistently met and did not always receive good quality care and support.

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 provider continued to have shortcomings with the leadership, management and oversight of the service. The provider had a manager working at the service, however we found ongoing concerns with the oversight of the service which left people at risk of harm. People experienced poor quality of care, and their safety was compromised by the lack of effective oversight. For example, the manager had failed to ensure safeguarding procedures were followed when incidents occurred which required reporting and investigation. This meant leaders were not providing the required level of leadership to ensure people consistently received safe, effective and compassionate care.

The provider did not always ensure open and honest communication was promoted with people, relatives, staff and other professionals. Systems were in place for staff to raise concerns, for concerns to be escalated and information to be shared with appropriate agencies and relatives. However, where an incident of potential abuse had occurred, other agencies and in some cases, relatives had not been informed about these incidents. This meant improvements were needed to ensure an open and honest culture was always fostered.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture promoting equality and equity for people who worked for them. The provider had an equality and diversity policy in place and considered the needs of their diverse workforce. Staff confirmed they were supported in their role and were able to raise any concerns to the manager when needed.

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. At our previous inspection, we identified concerns regarding the safety and governance of the service, and enforcement action was taken. During this inspection, we continued to find significant concerns relating to ineffective management and oversight which exposed people to the continued risk of harm. Concerns were identified with the safe administration of medicines and actions had not been taken to report the concerns for investigation. Care plans contained inaccurate information and the audit processes in place had failed to identify this. Where staff were not following risk assessments to keep people safe, there was no oversight system in place to identify these concerns and enable action to be taken. There was no effective system in place to ensure sufficient staff were available to meet people’s needs and preferences. The checks which had been put in place to identify concerns with the building had identified a lack of tamper-proof window restrictors, however action had not been taken to address this. We have since the inspection received information from the provider to say they have addressed some of the risks we identified. However, there had been no proactive approach to these issues, despite the previous inspection identifying similar concerns. This meant people continued to be at risk of receiving unsafe care and support.

The provider did not ensure they worked in partnership with other agencies to provide safe and effective care. The provider had a lack of effective oversight and robust monitoring in place to ensure they worked effectively in partnership with other agencies. We found advice was sought from other health professionals, but the lack of oversight in place meant where staff were not following the advice this was not identified. There were inconsistencies in how the advice of health professionals had been understood by staff and as records were not updated there was no way of knowing how staff should have been working to support the person. Oversight systems had failed to identify this and as a result people were exposed to the risk of ongoing harm. There was an inconsistent approach to how people were enabled to access the community. Where people required minimal support, they were able to access some community locations together as a group with staff. Whereas those who required more support were often left with minimal opportunities. The lack of oversight in the service had not ensured this was identified and actions were taken to address it.

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. Leaders had not ensured improvements identified as required at previous inspections were made, leaving people exposed to the ongoing risk of poor and unsafe care. We found whilst the provider had put systems in place to identify improvements and enable action to be taken, these were not always being followed. We found where incidents had occurred and care plans and risk assessments should have been reviewed, this was not always completed, which left people at continued risk of harm. The providers vision referenced a commitment to continuous learning and improvement, which would ensure people would receive care that was safe, responsive, effective, caring and well led. However, the systems in place had failed to identify and apply learning which kept people safe. For example, people were left at risk of choking as the systems had failed to recognise where staff were not following peoples risk assessments and care plans at mealtimes. This meant people were continually exposed to an ongoing risk of harm.