Garsewednack Residential Home

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• 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 good. 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 provider was in breach of the legal regulation relating to consent, dignity and respect and governance

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 clear shared vision, strategy and culture which was based on transparency, human rights, and engagement.

Due to a lack of mental capacity assessments in line with Mental Capacity Act 2005, the service could not be assured that people’s human rights were being upheld.

Shortfalls identified within this assessment in relation to respect and person-centred care, did not demonstrate a culture which had a joined-up approach, and care provision failed to be informed by the legal framework and best practice.

The registered manager did not always lead by example. We observed them shouting down the corridor to staff about individual people’s personal health information. This was not respectful to people living at the service and demonstrated a lack of regard for confidentiality.

This contributed to a breach of the regulation in relation dignity and respect and consent.

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.

While we received positive feedback about the management team from relatives, this assessment identified issues that led to breaches of legal regulations, which had not been identified and appropriate timely action had not been taken by the provider and registered manager.

The registered manager and provider did not identify their own learning needs and had not ensured they addressed gaps in their own knowledge. This meant they were not aware of relevant guidance to support safe, high-quality care and treatment. For example, they were unfamiliar with the Health and Safety in Care Homes guidance published in 2014.

Staff gave mixed feedback about feeling supported by the management team. They told us there was not always support available from the on-call team during out-of-hours.

The registered manager did not always follow the provider’s policies, including those relating to medication and supporting people who lack mental capacity to make decisions.

The provider did not always foster a positive culture where staff felt confident to speak up and have their voices heard.

Staff gave mixed feedback about the registered manager’s approachability and responsiveness to concerns. One staff member told us, “They (Management) are approachable”.

We observed concerns being raised with the registered manager and provider; however, they did not take responsibility for their lack of oversight, which had contributed to the breaches in the regulations. For more information see Governance quality statement, and Workforce wellbeing and enablement.

Records showed staff meetings were held regularly, and staff confirmed they attended these meetings.

Relatives felt the management team were approachable. Comments included, “Manager and all upper staff all approachable and there when you need them,” and “She seems approachable, she always finds a time to come and say hello when we are there”.

The provider valued diversity in their workforce. Although we received positive information from staff about the equality and equity. The staff did not always feel, the provider and registered manager were addressing concerns which had been raised.

Some staff told us they needed more support to carry out their roles and responsibilities. They told us they were not always listened to and that the registered manager did not always take appropriate action, which affected their ability to provide high-quality care.

The registered manager, provider, and staff acknowledged the team was diverse.

Staff told us they received reasonable adjustments to support personal circumstances. For example, reduced hours were offered and arranged. One staff member told us, “I feel welcome and part of the team, they gave me a present on my birthday”.

The provider did not have clear responsibilities, roles, systems of accountability, or effective governance. They did not act on the best available information about risk, performance, and outcomes, or share this securely with others when appropriate.

Systems and processes were not robust enough to identify all the shortfalls found during this assessment.

While care plans were reviewed by the staffing team, these reviews were not always effective. Risks to people’s health and safety were not always assessed, monitored, or updated, and the Mental Capacity Act 2005 was not being adhered to. Staff were not always given clear guidance, putting people at risk of harm. The registered manager was not auditing care plans to ensure reviews were effective, and current legislation was being followed.

We found one person’s risk of choking was not being managed. We raised this with the registered manager, who did not take responsibility for the lack of oversight or the ineffective audit process.

The provider did not have embedded systems and processes. Blank audit templates for call bells and legionella were in place, but these had not been completed.

Some audits were completed, but were not consistent, for example, a monthly medication audit had not been completed monthly.

The provider and registered manager did not have processes to monitor environmental risks, such as falls from height, and were unaware of measures needed to mitigate these risks for people living at the service.

Systems and processes had not identified institutional practices or ensured people were always treated with dignity, respect, and their privacy needs met.

The registered manager was not following the provider’s recruitment policy to ensure staff were safely recruited.

This contributed to the breach in relation to governance.

The provider did not always understand their duty to collaborate and work in partnership to ensure seamless services for people. They did not consistently share information or learning with partners or work together to drive improvement. We contacted professionals who told us they had no concerns about the service working collaboratively.

The registered manager had not always established or maintained safe systems of care to manage and monitor safety. Due to concerns under the learning, improvement, and innovation quality statement, the provider and registered manager were not continuously improving the service through effective collaboration nor seeking and acting on feedback.

The provider did not always prioritise continuous learning, innovation, and improvement across the organisation and local system. They did not consistently encourage creative approaches to deliver equality of experience, outcomes, and quality of life for people. They did not always contribute to safe, effective practice or research.

The registered manager and provider had been visited by the local authority and funded an external consultancy team, which identified several improvements. However, they did not act in a timely manner to implement these changes. For example, template audits were provided but not completed, and care plans requiring more detail and accuracy were not updated. The registered manager had not made improvements that could have quickly addressed these concerns.

The provider’s auditing process for incidents and accidents did not identify lessons learned to support continuous learning or improvement opportunities.

Staff did not always feel able to speak up, and action was not always taken following concerns raised.

This contributed to the breach in relation to governance.