Bognor Regis

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 inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulations in relation to the governance of the service.

This service scored 36 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. There were inherent risk factors and warning signs of a closed culture within the organisation and the provider had failed to act upon these. There was a lack of understanding by staff as to what a closed culture was. This meant people were more likely to be at risk of deliberate or unintentional harm.

The service did not have inclusive leaders who understood the context in which they delivered care, treatment, and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience, and credibility to lead effectively, and they did not do so with integrity, openness, and honesty. The provider had failed to report safeguarding concerns appropriately and ensure support practices were lawful or appropriate. The provider was unaware of their regulatory requirement to support people with a learning disability and autistic people in line with Right support, right culture, right care. There was failure to implement national best practice guidance, including the REACH standards which guide providers to the fundamental principles of supported living.

The provider had failed to create an environment where people with complex needs could speak up about their care and treatment. There was a failure by staff to understand their roles and associated responsibilities in relation to supporting people to speak up and raising concerns on people’s behalf. Staff were unsure how to raise concerns to outside agencies, particularly if the concern was about the provider. Staff told us they felt privileged to have employment with the provider and had not felt the need to raise any concerns with them.

The service valued diversity in their workforce. Policies and procedures supported this. Relevant legislation and best practice guidance was implemented to ensure staff were treated in a fair and equitable manner. Recruitment processes supported fair employment opportunities. The provider was registered as a UK sponsor for overseas workers and understood their responsibilities within this.

The service 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, or share this securely with others when appropriate. The provider's processes for quality assurance and audit were not robustly applied. Quality assurance checks had failed to identify out of date information, duplications across people’s care records and inconsistencies in information recorded about people. Governance process had failed to ensure people’s care experiences were in line with best practice guidance or that regulatory requirements were being met. The provider had failed to identify people’s tenancy agreements and living arrangements did not meet The Real Tenancy Test. The Real Tenancy Test is best practice guidance to help determine if a person’s tenancy rights are being met.In response to our feedback the provider sought professional advice about how to address the concerns we had identified with regard to people’s tenancy agreements.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. The registered manager did not attend local provider forums or local manager network groups. They had not ensured people and staff had access to information and organisations about people’s specific genetic conditions, so that information and learning could be shared and used to improve people’s care experiences. People used community services and facilities and participated in ordinary sessions. People had access to local health facilities and professionals for medical treatment.

The service 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. Models of care were not aligned to best practices guidance, including 'Right support, right care, right culture'.