Badby 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 requires improvement. 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 service was in breach of legal regulation in relation to governance at the service.

This service scored 32 (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 shared vision, strategy and culture based on transparency and equity, they did not understand the challenges and the needs of people within the service.

The provider had values known as the kite values where they aimed for kindness, integrity, teamwork and excellence. A staff member said, “The service’s vision and values focus on safe, caring, and person-centred care. There is a mission to support people’s well-being and independence, which guides my role every day.” However, we found the culture of the service was not always person-centred, inclusive and empowering.

Leaders, managers and staff had not consistently prioritised safe, high-quality, compassionate care. We received mixed feedback from people, their relatives and staff that described an inconsistent culture across the home where not everyone had a positive experience and felt listened to.

A staff member told us there was not an expectation to work over their hours but there was not enough hours in the week to complete their tasks, so they were working over their hours. We observed that a unit manager was called in from annual leave to support our inspection. This supported our concerns that there were not enough staff available and we observed that even with the managers arrival there was still not enough staff to support person centred-care at the meal time.

Policies and procedures were in place and in line with current best practice guidance around equality and diversity.
 

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. Not all Leaders had the skills, knowledge, experience and credibility to lead effectively, and they did not all do so with integrity, openness and honesty.

The provider had lost site of the inconsistent culture, safety and quality of the service because of poor systems and process for oversight of the service and a failure to create clear action plans with clear responsibility and accountability. A staff member told us, “We try to deliver person centred care but I feel there is resistance from staff, probably due to staff levels, staff who have been in unit so long and those who have been in care so long and won’t change their practice. Management put checks, paper work in to aid, but this is seen as a tick box only and staff feel under more pressure.” Another staff member said, “There is a bullying and threatening nature which has led to many losing faith in the leadership of the home.”

Some of the evidence we requested was not provided which suggested a lack of transparency regarding issues. There had been opportunity throughout the inspection to demonstrate that action had been taken on feedback, but this was not demonstrated.

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

The provider had a freedom to speak up policy. Information was available around the home to support speaking up but staff gave mixed feedback from across the units in the home on if they felt able to speak up. One staff member told us, “Staff have spoken, nothing changes, so staff are not interested.” Another staff member told us “I do not fear raising a concern; however, sometimes I feel like no action is taken”. Other staff spoke of a positive culture for whistleblowing. One staff member said, “The culture here makes it clear that it’s okay to speak up, which is reassuring”. Some staff described a blame and favouritism culture which had made them afraid to speak up. This reflected inconsistency across the service.

The provider did not always ensure all staff worked in inclusive and fair culture. The provider was an equal opportunities employer and ensured diversity in their workforce.

The provider had an equality and diversity policy and ensured a fair recruitment process. Staff work patterns could be adapted to support personal circumstances where needed. A staff member said, “The service respects our human rights at work and has supported requests for flexible working when needed.” Staff could access a muti faith room as and when required. However, not all staff felt listened to or treated fairly as recorded in other areas of this report with some staff fearing retribution for speaking out.

 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

Systems and process were not effective in ensuring the safety and quality for the service. For example, the provider was unable to evidence how they calculated the base number of staff required to ensure people received safe, good quality, person-centred care. A “staffing ladder” was used which we were told was used to increase or decrease staffing numbers as and when required such as if people’s needs change or they go into hospital and/or if oversight and feedback from staff supports the need to increase or decrease staff numbers.

We have found that oversight of the service was poor, staff were not always listened to, care was mostly task focussed and not always delivered as planned as recorded throughout this report. For example, on one unit we found the staff numbers had not taken into account breaks or the enhanced support needs of some people on the unit requiring more than one staff member during periods of the day. A staff member said, “Staffing levels are awful, stupid staffing ladder is not looking at the needs of the residents.” Another staff member told us, “The head of nurses and upper management are informed, there is not the time with the workload to take time to network and develop positive relationships.” Audits of records had not identified and actioned where staff had recorded the reason for not completing their workload as there not being enough staff.
 

Staff supervisions were not effective. Records evidenced that staff were raising concerns about the safety and quality of the service and the competency of staff during supervisions, there was no evidence that these concerns were listened to and actioned and quality and safety issues had continued. A staff member told us there was no value to supervision, they said, “Supervisions every month, same thing written each month.”

Audits were not effective in identifying and actioning concerns found throughout peoples care records, such as staff not adhering to planned care of PEG sites, errors in peoples medical records or repeated failures to ensure a DoLS condition was met.

We found that professional advice from contractors regarding the safety of the home was not listened to. For example, the provider had failed to take action to reduce the risk of fire as per the fire risk assessment and the fire evacuation policy did not provide clear guidance or instruction for staff. Gas boilers had continued to be used despite contractors advising they were unsafe. Advise on pest control had not been adhered to and rats had continued to live in the grounds increasing the risk of entry to the building and infection.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always collaborate well for improvement.

The provider had not always worked well with partner agencies to ensure the agreed and contracted quality of care was met. Where improvements were made, they were not always sustained, this meant the quality and continuity of care provided had fluctuated.

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

The provider failed to implement effective systems and processes to assess, monitor and improve the quality and safety of the service and as a consequence had been unable to achieve a good rating for the last 5 consecutive inspections.

Leaders shared ideas with us on how to improve the service some of which they started These would need to be actioned embedded and sustained to avoid the inconsistency of quality and safety evidenced at previous inspections that had lead to the service being unable to achieve a good rating.

A staff member told us that staffing numbers was a constant weekly battle. They said they were told by leaders how many staff was enough but often it wasn’t. They said when incidents and accidents increased more staff were deployed for a short period of time. As accidents and incidents decreased less staff were deployed. They said leaders did not understand that accidents and incidents had decreased due to better staffing and people’s needs were being met.

There had been a significant accident within the service that was being investigated separately from the inspection, however, we observed that lessons had not been learned and improvement had not been made to prevent future accidents for other people.