Ocknell Park

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 service 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. Systems were either not in place or not operating effectively, as they had not identified the shortfalls found at this inspection.

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 service 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.

Staff told us they were proud to work at Ocknell Park. Comments from staff included, “We are committed to people, and this gives a sense of community here”, “We respect people and put their needs first” and “We try to help them not think of themselves as residents, this is their home, we are their family. Me and them we are just alike. The thought that I have made someone at least smile, that’s just great for me.”

Not all leaders understood the context in which the service 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.

The registered manager was not always knowledgeable about issues and priorities for the quality of service and it was unclear where they could access appropriate support and development in their role. The registered manager did not always demonstrate or share an understanding of the risks, legal requirements and were not always clear about their responsibilities. Reporting of incidents, risks, complaints and concerns was unreliable or inconsistent.
Shortfalls in audits and gaps in records had not been identified by the provider. During the inspection, we met with the nominated individual who assured us they were committed to supporting necessary improvements and, following the inspection findings, had planned for an independent quality audit. The nominated individual is the person is responsible for supervising the management of the service on behalf of the provider.

People and their relatives did not always feel they could speak up and that their voice would be heard.

Concerns raised to the service were not always followed up or documented by the registered manager and management team. Adverse events had reoccurred as actions were either not taken or changes not sustained to ensure safety. Feedback received during the inspection was that leaders did not always listen and address issues.
Staff confirmed they had access to an independent whistleblowing telephone helpline should they wish to raise any concerns anonymously for any reason. During the inspection we asked to review these records and were informed that although the most recent investigation was complete, the record had not been updated. Therefore, the provider could not be assured all necessary actions had been taken including ensuring that lessons were shared and acted on

However, people using the service told us they had every confidence in the registered manager and staff on duty would support them if something went wrong.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures incorporated all aspects of equality, diversity, fairness and protected characteristics. Staff had regular team meetings to support inclusion and told us ways in which they seek support from colleagues to improve their resilience and develop their own skills.

Other resources were available to assist staff with their physical and mental health. This included an employee assistance programme, so that staff had the necessary access to services to thrive in their roles.
 

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

Governance systems were inconsistent and not always operating effectively. Systems had not been embedded to monitor the quality and safety of the care provided. This meant the provider had not identified the shortfalls found within this inspection.
Following the inspection, the provider told us they had invested in an electronic system for auditing which included incident recording and would improve oversight moving forward.
Leaders told us that they were confident that the proposed strengthened governance systems would deliver good quality, sustainable care, treatment and support, based on best information about risk, performance and outcomes.

Legal and regulatory requirements were met in relation to statutory notifications, which is information providers must share with the CQC about events which occur in the service.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

People told us, “We had our own funfair here, everyone cheered when I won hook-the-duck and I can go out all the time”, “Staff remind me to do things, but they don’t do it for me, I do it myself” and, “The staff take me to see my mum and dad.”

Health and social care professionals shared positive observations of activities being person-centred and interactions with staff when visiting the service. Comments included, “The registered manager quickly responds to questions or requests for a review and always works to a time that suits us. It is always a pleasure to work with them, and I know my patient is well cared for and enjoying their life” and “My client has shared nothing but praise for going to football games, museums, cinema...Staff have played a vital role in supporting my client’s ongoing recovery and wellbeing.”

The service 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.

Feedback from people and their relatives was sought by the service, however, actions were not always identified, improvements made, and lessons learnt. We found limited examples of where changes were made following accidents and incidents, and feedback from people and their relatives. Staff and leaders did not ensure that people using the service, their families and carers were involved in developing and evaluating improvement and innovation initiatives. The service did not always have robust processes to ensure they continually improved. Many of the processes were incomplete and not followed as planned. These shortfalls had not been identified by the provider’s governance arrangements and oversight of the service.