Pelham Grove Care Home

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 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 good. At this assessment 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.

This service scored 50 (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. They did not understand the challenges and the needs of people and their communities. For example, the provider’s systems and processes did not effectively assess, monitor or improve the quality and safety of the service, and there was no clear indication learning had taken place following safety events. We were not assured information relating to incidents and accidents was routinely shared across the staff team, which contributed to a culture where important information was not consistently communicated.

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. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. For example, the registered manager lacked some understanding of their responsibilities to notify the relevant agencies, including the local authority, about events occurring at the home.

However, people and staff told us they felt able to approach the managers with any concerns and were confident they would be listened to and their concerns would be acted upon. One person told us, “The manager is great, you always see them.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. For example, managers were accessible, visible and kind when speaking with staff. Staff told us they trusted the managers and were confident they could approach them. Regular staff meetings and daily handovers where managers attended fostered a sense of teamwork. One staff member told us, “[Manager’s] door is always open, I can go in with any problem I have and know [manager] will listen.”

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. For example, staff had access to the provider’s policy which set out a clear commitment to promoting equality, diversity and inclusion within the workplace. Staff told us they felt they were treated fairly and described feeling valued and respected by managers. They spoke positively about the personal support they had received, particularly when experiencing individual or personal challenges, telling us the manager was understanding. All staff had completed equality, diversity and inclusion training, which supported the provider’s approach to fostering an inclusive and supportive workplace culture.

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. For example, there was an overall lack of effective oversight and scrutiny by the provider and registered manager to ensure risks were properly identified, monitored, and mitigated. Governance systems were not robust, and audits and quality checks were not consistently completed to monitor, assess, and improve the quality and safety of the service. Systems in place did not reliably identify gaps or errors within care records. They failed to highlight where mental capacity assessments had not been completed or where applications for Deprivation of Liberty Safeguards (DoLS) authorisations had not been submitted when required. Medicines audits were ineffective and did not identify shortfalls in ‘when required’ medication protocols, including insufficient detail on when medicines should be administered or missing records of the reasons for administration.

In addition, governance processes did not identify where essential risk assessments were absent, including those relating to specific clinical risks such as diabetes or the use of flammable creams.

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. For example, regular meetings were held with other external professionals to discuss and coordinate people’s ongoing care. A visiting professional told us they regularly provided guidance and advise about peoples care and staff consistently followed this.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. For example, a lack of analysis of events such as accidents and incidents led to missed opportunities to identify trends and make improvements to reduce the risk of further occurrences. The management team were unable to demonstrate where learning had taken place and been used to make improvements to ensure positive outcomes for people.

Improvement plans we reviewed did not identify any of the concerns we found during this assessment.