244 Wootton Road

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 inspection we rated this key question Good. At this inspection the rating has changed to 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 transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Improvements were required in governance of the service to ensure it was robust and effective in day-to-day quality assurance. Audit processes needed strengthening to help the management team identify required problems and the actions required. We looked at a range of audits, and these did not always identify our findings during this inspection.

The provider had an improvement plan in place to address some of the work needed to improve the environment such as refurbishing the shower room.

We raised the concerns we had found during our inspection with the registered manager and the provider; they were responsive and took action to address some of the issues immediately and developed an action plan to address the other improvements required.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

We received overwhelming positive feedback regarding the manager, and the support staff receive from them, however, we received some concerns regarding the support the manager receives and the manager’s workload. One staff member told us, “My manager and deputy manager give me support although they are very much under pressure themselves. I feel valued by them, but not by the company who employ me. It is very demoralizing at times.” The manager did not have a full time line manager in place to support them after they have left the company, the provider was looking to recruit a suitable replacement and an-interim line manager had been put in place.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff said that they felt able to share their views and raise any concerns they may have. One staff member told us, “I am confident in reporting or raising concerns, so they are taken seriously and acted upon promptly.”

The provider had a whistle-blowing policy. This meant that staff knew the actions they should take if their concerns about people’s safety and wellbeing were not addressed by leaders.

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.

244 Wootton Road had a diverse workforce and all the staff we spoke with told us they felt valued, respected and well supported by the manager.

Staff received training in equality and diversity. This meant staff had an understanding about discrimination and anti-discriminatory practice.

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.

We found the management of 244 Wootton Road was mainly being conducted from the other service, which was managed by the registered manager. Although, the 2 services are run by the same company with the same registered manager they have separate registrations. We found that paperwork included both services which was confusing. It also led to care plans and other information not being on-site which could have placed people at risk.

Audits were completed on a regular basis; however, they had not always identified areas of concern that was found during the inspection process.

We found that CQC notifications had not always been submitted as required.

We received mixed feedback from staff regarding the responsiveness of the provider in relation to IPC concerns and environmental health and safety issues, one staff told us, “Very rarely are things dealt with quickly.” While another said, “All issues are normally dealt with in a timely manner.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

We saw evidence of partnership working with GP's, learning disability nurse and SALT team.

People were supported to access the community as they wished, including taking the bus or the train to participate in activities further away from the home.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

The provider did not have adequate quality assurance systems in place, this meant that we were not reassured that all incidents that could have been identified as lessons learnt were addressed. For example, documents reviewed showed that 1 person had received cuts during shaving with a razor on at least 2 occasions due to their distressed behaviour, we could not see that lessons had been learnt from this.

The provider had a quarterly lesson learnt newsletter which they shared amongst all of the services. This included a range of different topics and updates.

Concerns identified during the inspection surrounding staff training and competency checks had not been identified by the service.