Little Hayes

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 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 good governance.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although the provider had a clear shared vision, which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement, this had not been embedded across the service.

The providers statement of purpose set out a clear vision to provide person-centred care, prioritising dignity, respect, and creating a safe and homely environment.

Staff interactions with people were observed to be kind and respectful, and some staff described the service’s values as focused on person-centred care. One staff member said, “we like people to feel it is their home.” However not all staff were able to clearly describe the services visions and values. One staff member told us “They do, but I can’t remember it.”

Furthermore, inspection findings identified concerns relating to person-centred care plans and the safety of the environment, which directly relate to the service’s stated objectives.

This gap between leadership’s stated direction and staff understanding could limit the consistent delivery of high-quality, personalised care.

Not all leaders had the skills, knowledge, experience and credibility to lead effectively.

Leaders did not consistently demonstrate sufficient capability to identify and address risks in a timely way. Significant concerns relating to medicines management, environmental safety, infection prevention and control, consent and care planning were not identified or effectively managed until highlighted by inspectors. Leaders did not ensure staff had clear, up-to-date guidance and training to meet people’s complex needs.

As a result, people were exposed to the risk of avoidable harm, including unmanaged pain, increased risk of falls, infection risk and unsafe access to exits. Staff lacked consistent direction in supporting people safely. Although leaders showed care and willingness to improve, these shortfalls meant leadership was not consistently effective, which limited the service’s ability to deliver safe, person-centred care.

Leaders were accessible and engaged with people and staff and demonstrated a respectful and caring approach. They engaged positively with inspectors, listened to feedback and responded respectfully to concerns raised during the inspection. Relatives told us they felt able to raise concerns and be listened to, which reflected inclusive leadership. However, leaders told us they were responsible for managing more than one service, and that this impacted the time available to maintain consistent oversight and presence within the service, something they have raised with the provider.

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard.

Staff told us that they felt able to raise concerns with the management team and felt they would be listened to. Comments included “Leaders encourage openness and reporting” and “I understand freedom to speak up as raising concerns safely and without fear”.

There was a raising concern, freedom to speak up and whistleblowing policy and procedure available to staff.

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 manager told us they fully supported flexible working and staff confirmed this. Staff told us that they had no concerns about the way the service treated them.

Staff received equality and diversity training, and the provider had policies in place relating to equality and diversity.

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

The provider had a range of quality monitoring procedures in place including audits of various aspects of the service. However, audits and governance procedures were not effective and had not identified the issues we found during the inspection as detailed in the various sections of this report. This included medicine management, risk management and mental capacity and consent documentation.

Two staff risk assessments were either not sufficiently robust or had not been reviewed in relation to their health needs. The provider took remedial action as soon as they became aware.

Governance systems did not consistently ensure that care was delivered in line with people’s assessed needs, and care records were not always sufficiently detailed. Processes in place failed to guarantee that records were complete, accurate, and contemporaneous. We observed examples where people’s care records were incomplete or lacked the necessary detail for staff to manage specific needs or complex conditions safely. This increased the risk of inconsistent care and reduced staff’s ability to respond effectively to people’s needs.

The provider did not maintain robust records or systems to oversee health and safety within the service. Routine maintenance audits failed to identify missing window restrictors in areas where they were required and exposed hot pipework, placing people at risk of injury. These shortcomings demonstrated that governance and management systems were not effective in sustaining a safe and well-managed environment, leaving people vulnerable to avoidable harm.

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.

Professionals told us the service was proactive in seeking advice and responsive to feedback. One professional said, “Our working partnership has been such that we have always been able to be open and honest about feedback relating to our service and individuals involved.” Another told us, “Individuals appear to be appropriately supported with their holistic needs in this care setting.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider did not have an effective system to monitor, evaluate, and drive improvement in the quality and safety of the service. Although an audit action tracker was in place, it had not identified the issues we found during this inspection, as detailed elsewhere in this report.

Management were open to feedback during the assessment and demonstrated a willingness to address shortfalls. However, the lack of robust monitoring systems limited their ability to learn from incidents or audits, and opportunities for improvement and innovation were missed, reducing the effectiveness of the service in ensuring consistently safe and high-quality care.