Index Care 88 Abbey Wood 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 good governance to the management and maintenance of safe environments 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.

The service had policies in place that reflected current best practice guidance. Records of meetings showed learning and planned improvements were shared with staff and people’s relatives.

The management team completed regular audits across key areas of the service to identify and manage risks and drive improvement. This helped ensure people were cared for safely, their needs were met through person-centred care planning, and equality was promoted. The service had systems in place to support safeguarding, and people were encouraged and supported to raise concerns, which were acted on appropriately to help keep them safe in the service and the wider community.

The provider did not show capability in relation to providing a safe and risk-free environment to support people in. The provider had addressed some of the environmental safety issues notified by external agencies. However, further improvements were required to strengthen fire safety arrangements. Safety in relation to adequate flooring to prevent the risk of avoidable harm had not been implemented at the time of the assessment. Many aspects of the environment, like ensuring the building did not have sitting mould, still required improvement. The provider had effective systems in place to ensure staff were safely recruited. Staff received an induction at the start of their employment and ongoing training to support them to meet people’s needs safely. Managers understood their responsibilities to notify the Care Quality Commission (CQC) of incidents and events in line with regulatory requirements. The service had policies and procedures in place to support safe, consistent care and to protect the wellbeing of people and staff.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The service had a complaints policy in place, which listed the process of how complaints could be made, and what they should expect. Relatives told us they were able to contact the service to raise concerns, if required

The service had a whistleblowing policy in place. This contained contact information so staff could contact the local authority or CQC with any concerns if required.

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. The registered manager was supported by their management team to take appropriate action to address inequalities in staff experiences. This helped reduce the risk of discriminatory practices and promoted fairness across the workforce.

The registered manager told us they felt well supported by senior management, which helped ensure staff wellbeing was maintained. The provider had equality, diversity and inclusion policies in place, and staff had received training in equality and diversity to support inclusive and respectful working practices.

The provider did not act on the best information about risk in relation to the safety of the environment. Carpets on the stairs were worn and torn, and there was a hole in a step riser, which increased the risk of trips and falls. Mould was present in an upstairs bathroom and on the window in the living room, indicating ineffective maintenance and infection prevention. Structural alterations to the building meant there was no assurance that a fire door on a potential escape route would remain fire resistant for the required 60 minutes, increasing the risk of avoidable harm to people in the event of a fire.

The provider had systems in place to monitor the quality of care, including audits and action plans, and staff received appropriate training to support people safely. Records showed staff meetings and supervisions were held as required. Statutory notifications were submitted to the CQC and relevant partners when incidents, accidents, or safeguarding concerns occurred.

However, these governance systems had not effectively addressed risks within the environment, limiting their effectiveness in keeping people safe.

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. The management team demonstrated a good understanding of the local community and worked effectively with a range of services to promote people’s social inclusion.

People were supported to access and participate in community-based activities that reflected their interests and preferences. The registered manager recorded clear guidance on duty rotas, so staff were prepared to support people to attend activities. Activities included coffee mornings, dance and exercise groups, life skills and drama workshops, and social events such as discos.

These opportunities helped people remain active, develop skills, and maintain positive relationships within their community.

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. Staff were encouraged to share ideas and feedback through staff meetings, supervisions, and group communication channels, supporting an open and inclusive culture. Training records showed staff received appropriate training to support people safely and deliver effective care. Accidents and incidents were recorded accurately, with actions taken, lessons learned, and preventative measures clearly documented. People were supported to attend regular meetings to discuss their care needs and share ideas with the management team.