Shirelodge Nursing Home

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 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.

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, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

We received mixed feedback from staff about working at the home. Whilst some staff told us they enjoyed their roles and valued the relationships they had developed with people living at the service, relatives and colleagues, they were not consistently able to describe the provider’s vision.

Feedback received from staff and our findings throughout the assessment identified concerns regarding the culture within the service. Staff did not consistently feel valued, supported, or listened to by leaders, and many described a disconnect between the provider's expectations and their lived experience of working at the home. This was reflected in the feedback received regarding leadership, speaking up, and workforce culture.

Work was required to clearly define and communicate the strategic direction of the service and to establish a culture that promoted openness, learning, accountability, and continuous improvement.

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. 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's nominated individual and registered manager were known to people, relatives, staff, and external professionals. However, we received mixed feedback in relation to their visibility. A person told us, “I’ve never seen the manager.” Another person told us, “Don’t see the manager, none of us see [manager].”

The majority of the feedback we received from staff regarding the leadership and management of the service did not demonstrate the characteristics of compassionate, inclusive, and supportive leadership.

Staff consistently described experiences that suggested they did not always feel valued, respected, or supported by leaders.

We received positive feedback in relation to other staff within the service who contributed to the leadership team. For example, clinical lead team leaders and the head of care.

At the time of our assessment, we were not assured that leaders had established a compassionate, inclusive, and supportive culture for staff, or that there was suitable leadership capability to drive improvements.

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

The provider had policies and procedures in place relating to whistleblowing and had recently engaged an external speaking-up service to support staff to raise concerns.

Feedback we received during the assessment indicated that staff did not always feel able to speak up freely or raise concerns with confidence. During the assessment, we received information from multiple sources suggesting some staff were reluctant to speak openly about their experiences within the service.

We were also informed that some staff had concerns about being observed while speaking with inspectors. This meant we took steps to provide opportunities for staff to speak with us in safe environment.

The majority of staff we spoke with told us they lacked confidence that concerns raised internally would be listened to, acted upon, or result in positive change. Some staff expressed concerns that raising issues could negatively affect their working relationships or employment experience.

We also received information from a number of sources indicating that comments had been made which staff interpreted as discouraging them from expressing negative views about the service or its leadership.

While we did not seek to substantiate individual accounts to protect the identify of people raising concerns, the consistency of the feedback received contributed to concerns about the culture within the service.

We were not assured that leaders had created an open, transparent, and psychologically safe culture in which staff felt empowered to speak up, challenge poor practice, or raise concerns without fear of adverse consequences.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had policies relating to equality, diversity and inclusion and employed a diverse workforce across all departments of the home.

We received mixed feedback from staff in relation to leaders not always taking action to improve the experience of staff with protected equality characteristics.

While some staff told us the provider had made reasonable adjustments to support them in their roles, others reported that leaders were not supportive of staff with protected characteristics and did not always respond fairly and appropriately to their needs.

We could not be assured that the provider and registered manager had established and sustained a positive, inclusive, and fair workplace culture that actively supported equality, diversity, and equity for all staff. This increased the risk that some staff may experience disadvantage or feel unable to raise concerns about their wellbeing and support needs.

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, or share this securely with others when appropriate.

The provider had systems and processes in place to assess and monitor the quality and safety of the service. However, these systems were not effective and had failed to identify, assess, monitor, and drive improvements in several key areas of the service. The provider had failed to identify many of the shortfalls identified during our assessment.

During the assessment, we found significant weaknesses in the provider's oversight of care planning, health and safety, medicines management, mental capacity assessments, infection prevention and control, and staffing arrangements. Auditing and quality assurance processes had failed to identify concerns we found. For example, audits had not identified the concerns we found in relation to mental capacity assessments.

There was some evidence of oversight visits undertaken by members of the provider's senior leadership team. However, records of these visits did not demonstrate effective scrutiny of the service and failed to identify the concerns and risks found during this assessment. This meant provider-level oversight was ineffective in assuring the quality and safety of the service.

There was no evidence that regular management walkarounds were taking place. We found a number of environmental, health and safety, and medicines management concerns that could have been identified and addressed through routine and effective management oversight. This demonstrated a lack of operational governance and day-to-day monitoring.

Prior to the start of our assessment, we raised concerns with the provider about the lack of statutory notifications submitted to CQC in relation to allegations of abuse. In response the provider undertook a review of its records and submitted a significant number of retrospective notifications for the previous 12 months. However, we remained concerned not all notifiable incidents had been reported to CQC.

Our assessment found widespread and significant shortfalls. We identified regulatory breaches relating to safe care and treatment, consent, safeguarding, staffing and good governance. This meant people were placed at risk of not receiving planned care and have been exposed to the risk of unnecessary harm due to poor governance.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The registered manager demonstrated engagement with external partners and professional networks. They attended local authority forums, participated in the Skills for Care Registered Managers Network, and the provider was a member of the Northamptonshire Association of Registered Care Providers (NORARC). These arrangements provided opportunities to share good practice, access support, and learn from developments within the adult social care sector.

However, we found that learning gained through these partnerships had not always resulted in meaningful improvements within the service. For example, the public health team shared they had previously asked the provider to map out a timeline in relation to the outbreak. However, this information was not freely available during our assessment.

This demonstrated that while the provider and registered manager actively engaged with external organisations and learning opportunities, they were not always effective in embedding learning into practice.

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 did not have effective systems and processes in place to identify, analyse, and learn from governance activities, including accidents, incidents, audits, and other quality assurance processes.

There was no effective service improvement plan in place, and quality assurance systems did not provide leaders with adequate oversight of the service. Audits relating to care planning, medicines management, infection prevention and control, and the environment had failed to identify the majority of concerns we found during our assessment.

The provider shared a root cause analysis (RCA) relating to a recent infectious outbreak. The RCA lacked depth and critical evaluation. It did not adequately explore the factors contributing to the outbreak, identify opportunities for organisational learning, or establish clear actions to strengthen infection prevention and control systems and processes. The provider was unable to demonstrate that meaningful learning had been achieved from the outbreak.

Leaders did not have effective oversight of systems and processes to support learning, improvement, and innovation. Governance arrangements had failed to identify significant concerns and drive the improvements required to ensure people received safe, high-quality care. Where concerns had been recognised, these were not recorded within a service improvement plan, monitored effectively, or addressed in a timely manner.

Although the provider was receptive to the feedback we provided during the assessment and told us about some immediate improvements they were making in response to our feedback, we were not assured that the service had established a culture of continuous learning and improvement. Opportunities to learn from governance processes such as accidents, incidents, audit findings were routinely missed. This meant there was an increased risk that identified concerns would reoccur and that improvements would not be sustained.