Stratford Road

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 regulation 17 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.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights. The provider had not embedded structured governance systems to identify recommendations in service delivery.

The provider did not always work in line with the underlying principles of Right Support, Right Care, Right Culture guidance. Unnecessary restrictions were in place, and these had not been reviewed to explore whether less restrictive options were available.

Whilst the provider ensured staff had access to specific training to support autistic people and people with a learning disability, there was evidence staff did not always fully practice what they had learnt. For example, we saw staff talking about people in their presence without involving them.

Leaders did not always understand the context in which the provider delivered care, treatment and support. The service had been without a registered manager for 9 months. The acting manager told us attempts to recruit had been unsuccessful.

People, families and relatives spoke positively about the management of the service. However, operational leadership did not consistently translate into effective management including governance systems which meant some areas of practice were not always effective. For example, audits carried out by senior staff which highlighted where improvements were needed were not always carried out.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. A person we spoke to told us they could talk to any of the staff if they were concerned and knew in particular that they could talk to managers.

Staff told us they could approach the manager if they had concerns and were aware of the provider’s whistleblowing policy if they needed to use it. A staff member told us,” There is an open-door policy here, no matter what is going on, we are always offered support.”

The provider worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff had access to a comprehensive training package to ensure they were given an opportunity to learn the skills they needed to do their job. Supervision records showed managers were meeting regularly with the staff team to review practice and development.

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

Audits were not robust and had failed to address concerns raised by other agencies and address shortcomings in recording practices. For example, the providers governance processes had failed to identify and address fire safety risks to ensure people were kept safe. The service failed to identify gaps in medicines recording systems. The provider failed in their responsibility to notify CQC following applications being granted to deprive people of their liberty.

Systems for identifying hazards were not robust. Items which were either broken or which required more appropriate storage had not been identified.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. People had health action plans and were supported to access a range of external health professionals. The service had recently been working with a health care professional to carry out a needs assessment of a person. The professional told us how they valued the input and their knowledge and understanding of the person which assisted in carrying out a more comprehensive assessment.

The provider did not always ensure they delivered equality of experience, outcome and quality of life for people. They did not always actively contribute to safe and effective practices. The service did not use knowledge around mental capacity and DoLS to understand practices were not in line with expected standards.

Values covered at induction and throughout learning were not always followed. People were not always given the privacy, dignity and respect they were entitled to.