Creative Support – Hall Lane

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 remained 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 the legal regulation in relation to governance at the service.

This service scored 54 (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 and culture, but improvement was required to ensure it was embedded throughout the service as the culture of staff and the feedback received from some staff meant we could not be assured the culture of the service was always positive.

The home manager spoke of a positive direction in the service. Some staff told us they were not happy in their roles and there was a divide between the management team and staff which did not support a good working environment. However other staff said management were, “Good, they listen to staff. They are approachable.” It was clear that at this time, there was a lack of transparency and openness between staff and the management team which had created an uneasy working environment.

During our inspection the provider showed evidence of how they had tried to improve the culture including a conference held to discuss cultures, and regular staff meetings. Various policies were in place to support an open culture, and the registered manager told us, "Equality, diversity and inclusion teams are available monthly for chats with staff should they wish to discuss any concerns. Staff do come to me and say they have a concern.”

We have spoken to the provider about the concerns of developing a poor culture and they assured us they would be addressing this through meetings to facilitate open communication and take action as required.

The management team and staff understood and supported people’s cultural and spiritual needs. People were treated equally, and their individual needs considered when completing care plans in line with their preferences.

Leaders understood the context in which the provider delivered care, treatment and support. However, further improvements were needed to ensure they had full oversight of the care provided at the service. The provider did not always embody the culture and values of their workforce and organisation. We received mixed feedback from staff on the support they received from the management team. For example, some staff felt unable to share any concerns whist others felt well supported and that the manager was compassionate. One staff member said, “It’s a happy environment, happy to come here. I feel able to raise concerns with the manager. Definitely will feel able to report any poor practices.” However, some staff told us the management team were not inclusive and felt the service was poorly managed.

We also received mixed feedback from relatives. Comments included, “I would like more contact”, “They listen to concerns but do not always act upon it. I never see the manager” and “It is well managed at the moment.” During our inspection the management team were honest and open to our findings and feedback.

The provider had sought to keep people, their relatives and staff update to date with information about people and services through monthly newsletters, magazines and regular contact. The provider had also sent surveys to gather feedback about their experiences.

People did not always feel they could speak up and that their voice would be heard. We received mixed feedback from staff about their experiences of speaking up. Some staff felt able to share concerns whilst others didn’t. The provider had a poster in all areas of the service called ‘We value your feedback’ with a QR code for staff, service users and relatives to give feedback whether this was anonymously or not.

The provider had a proactive and positive culture of safety, based on openness and honesty. The service listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Where incidents had increased, we saw evidence of multi-disciplinary working with social workers and health professionals to ensure people were kept safe.

The provider did not always have clear systems of good governance. Audits were not effective as they did not always identify the concerns we found on inspection. The provider’s actions following audits had not always been completed in a timely manner and were not clear. Records pertaining to care files, medicines and mental capacity assessments were not always accurate or completed. Following our feedback the provider immediately updated these to reflect current care. We could not be assured there was sufficient oversight.

Although we found no evidence of harm, this was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider had a proactive and positive culture of safety, based on openness and honesty. The service listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Where incidents had increased, we saw evidence of multi-disciplinary working with social workers and health professionals to ensure people were kept safe.

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. Monthly analysis of incidents took place, and the manager shared any lessons learnt within staff meetings. The company also shared lessons learnt across services to improve practices.