Georgina 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 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 provider was previously in breach of the legal regulation in relation to governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

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 lacked a clear vision and culture centred on transparency, equity, equality, and human rights. There was a lack of management and provider oversight to ensure that the ‘Right support, right care, right culture’ was being considered in accordance with guidance.

Leaders had failed to ensure that autistic people and people with learning disabilities lived ordinary lives like any other person. There was a lack of provider oversight to ensure people were supported to grow their independence and have access to activities that were meaningful to them. There was no evidence that these areas had been audited, and the registered manager had not identified our concerns in relation to person-centred care.

However, the registered manager described the service's key values: striving for excellence, putting people first, acting with integrity, and being supportive. Both staff and leaders demonstrated a positive, compassionate, and listening culture that promotes trust and understanding between them and the people using the service. Staff understood equality and diversity and prioritised safe and compassionate care.

Leaders did not have the skills, knowledge, and experience to lead effectively. We identified breaches of legal regulations and concerns in areas such as safe care, person-centred care, and governance. Leaders had not independently identified some of our concerns. When concerns were identified, they were not acted on before our assessment, such as broken furniture in people’s bedrooms, which was first reported in October 2024.

While we found some areas of improvement in the service, we also continued to find areas of concern, as reported in the other quality statements.

We received mixed feedback from staff about the service's management structure. The registered manager is responsible for management oversight at 2 different locations and is, therefore, not always on-site. Some staff were happy with the current arrangements, but others felt having a permanent manager who could focus entirely on one service would be more effective.

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

Staff provided mixed feedback. Although staff were encouraged to voice their ideas for improving the service, they didn’t always feel listened to, as their suggestions were not always taken forward. Other staff we spoke to also felt listened to.

However, the registered manager confirmed they had an ‘open door’ policy at the service. They said, “Staff can talk openly and honestly without repercussions.” There was a facility for staff to access a confidential whistle-blowing helpline, if they wished to do so. The registered manager told us staff at the home also had access to a ‘Freedom to speak up champion’ should staff need to raise concerns about anything that may negatively impact people’s care or workplace wellbeing. The area's Operational Director and Quality Lead regularly visited the home, which provided another platform for staff voices to be heard.

Staff confirmed the registered manager would provide a debrief following incidents at the service. These were sometimes discussed during supervision meetings.

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. However, we did identify some cultural issues within the service that required improvement.

Some staff felt the workload was not shared equally among the whole staff team, which was unfair. Staff told us they were happy to raise these concerns with the registered manager, but did not have confidence that the registered manager would address the issue.

However, staff felt safe working at the service. The registered manager confirmed the service was flexible and had agreed to allow staff members to reduce their hours.

All staff completed a staff survey in April of this year, which included several questions relating to teamwork, growth, diversity and inclusion, leadership, empowerment, recognition, communication, and previous survey actions. The purpose of the survey is to measure colleague satisfaction and motivation levels. Actions from this staff survey include engagement events and activities for staff.

The registered manager confirmed that the service has a bullying hotline should staff need to speak to someone confidentially. Staff had also completed diversity and inclusion training.

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.

The quality assurance systems at the service included regular audits. These included medicines, health and safety, bedroom, housekeeping, infection prevention and control, kitchen, dining and nutrition, and a manager’s quality walkaround. There were gaps in the system, and the registered manager audits had failed to identify the concerns we found relating to fire safety, safe recruitment, environment, staff training, staff competency, and medicine records. Despite the registered manager identifying concerns within the service’s bedroom, housekeeping and infection prevention and control audits, no remedial action had been taken before our assessment.

Furthermore, there were no formal care record audits, audits of staff interaction, incidents and accidents, or safeguarding. Overall, this meant that the registered manager’s audits were not effective. There were also no provider audits. The registered manager could only provide one record of meeting minutes, evidencing concerns and subsequent actions, despite being asked for more.

Management oversight was lacking regarding staff training. We could not be assured that all staff had been trained to provide safe and effective care. For example, not all lone working staff had completed mandatory medication administration and fire marshal training in accordance with the provider's policy. Some staff competency assessments had not been completed in line with national guidance.

We also found concerns relating to safe staff recruitment, with several pieces of missing information. During our on-site assessment, we saw several infection prevention and control and environmental concerns, including fire safety.

Records were not always completed or accurate. There was some disparity between care plans and their format. For example, information about a person’s sensory needs was recorded within the ‘living my life’ plan, whereas another person had a separate ‘sensory profile’ plan. This could make it difficult for staff to know where to find the correct information at the right time. Medicine records lacked detail. There were several missing shift handover records.

The registered manager had failed to ensure that people received person-centred care that reflected their needs and preferences, including personalised activities, and that the environment was appealing and met people’s sensory and physical needs.

The governance and oversight of the service were not used to develop an improvement plan for the service.

However, most concerns relating to the environment and infection prevention and control were rectified during our assessment.

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.

We saw evidence of external professionals involved in people's care, such as GPs, nurses, dentists, opticians, and social care staff, including social workers and best interest assessors.

A social care professional said that the staff were well informed about the person they were completing a review for. Staff were friendly and always responded in a timely manner.

The service had access to an in-house psychology team and could self-refer to the local mental health and learning disability services.

The provider did not always focus on continuous learning and improvement across the service. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The service needed to improve its systems to ensure learning always occurred and quality concerns were addressed. Although systems were in place to audit medicines, health and safety, bedroom, housekeeping, kitchen, dining and nutrition, and a manager’s quality walkaround, they had not addressed the shortfalls we found.

The provider implemented an action plan following conditions imposed on their registration at the last inspection. However, this plan failed to address our previous concerns. At this inspection, we found some limited improvements, including additional staff training, referrals to outside agencies for people’s specific needs, and creating a safe pathway in the garden. However, we did not find evidence of sustained improvements across all areas.

The provider supported staff in completing health and social care qualifications. It offered pathways for all existing staff to help support career progression and had in-house reward schemes, including ‘employee of the month.’