Thanet House

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 provider was in breach of legal regulations relating to good governance.

This service scored 46 (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, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities and did not always focus on learning and improving.

The recent concerns indicated poor practices had not been identified by the provider or registered manager. Whilst the registered manager and provider showed a willingness to improve the culture within the service, this required time to establish and embed improvements.

Staff told us there was a shared vision and culture. One member of staff told us the aim of the service was “to make sure people are living theirbest life”. However, the shortfalls in delivering safe, person-centred care meant we were not assured the vision was shared and understood by all staff.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

There was a lack of robust management and oversight of the service. Audit and governance systems in place were not always robust and effective and had failed to identify concerns and areas for improvement at the service.

We were not assured leaders had the skills and knowledge to manage a service specialising in delivering care for people with mental health needs, autistic people and people with a learning disability. The registered manager could not show they had undertaken relevant training to manage a service with these specialisms. We also found there were other senior managers conducting checks and audits of the service but there was no record of their training, so we were not assured they had the skills and knowledge to conduct these quality assurance checks effectively.

Staff told us they could speak up and their voice would be heard. They told us they thought there were effective systems in place for them to raise any concerns and they felt confident action would be taken if they did.

Staff told us they were supported to have their say and make suggestions for improvements through regular individual supervision and group meetings with their manager. A staff member told us, “To me freedom to speak up means being able to say whatever is bothering me without any fear of intimidation or victimisation.”

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. Staff from diverse backgrounds reported feeling respected and valued and they described leaders as fair, approachable and supportive.

Systems to monitor the quality and safety of the service were not effective. The provider’s quality assurance systems did not identify all the concerns found during in relation to the management of risks, medicines, staff recruitment and training and person-centred care. When audits did identify shortfalls the identified actions were not always followed up and/or completed.

Medicine audits were being carried out monthly but they were of limited assurance as they did not identify the issues we found. Audits also did not indicate which person’s medicines had been audited and did not include a check that the correct stock was in place. A recent medicine audit also stated a weekly check would be put in place with immediate effect, but this has not happened and the registered manager was not aware of the rationale for this action.

Environment audits had not been effective in ensuring the safety concerns in relation to the balcony and fire escape were acted on. These shortfalls created significant risks to safety, consistency and the provider’s ability to assure ongoing quality of care.

The provider understood their duty to collaborate and work in partnership however partnership working was not always effective in improving outcomes and some people had little access to community resources.

Records showed good support for some people from external professionals such as community mental health teams, however, this was not consistently done for all people receiving care and we saw examples where people would benefit from support and input from external health and social care professionals.

The provider did not focus on continuous learning, innovation and improvement. They did not always encourage creative ways of delivering equality of experience, outcomes and quality of life for people. Persistent gaps in documentation, lack of robust auditing and failure to identify issues before the inspection showed effective learning systems were not embedded.

The provider had produced an action plan in response to concerns raised by the local authority commissioners. However, there was limited evidence of sustained, proactive quality improvement. Although the provider had started to address some of the issues identified we found improvements were not always in place or sustained despite being recorded as completed on the provider’s action plan. This failure to accurately record progress towards actions undermined confidence in the provider’s ability to focus on continuous learning and improvement.