The Coach 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 service was in breach of legal regulation in relation to governance at the service.

This service scored 54 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff were very passionate about providing good care to people that met their needs. One member of staff said, “We want to empower residents, for them to have a sense of belonging and control for a good quality life.” People were receiving person centred care and staff were inclusive of people’s relatives and advocates when planning care needs. Each person had a keyworker who worked closely with them and their relatives to ensure they were experiencing personalised care.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. The service had been through a period of change, there was a new manager in post who was not yet registered with the commission. The manager had spent time identifying issues at the service but did not have a clear action plan in place with how they would address any issues such as staff training, the environment and the general running of the service. Some staff had told us they found the new manager to be supportive and was helpful to their role. Other staff expressed they were unsure of the new manager and changes they had tried to implement. Some staff expressed concern that they were unsure if the manager would be staying at the service or whether they were there short term and they would then need to get to know another manager.

The service had systems in place to gain feedback from relatives and people. Keyworkers contacted family members monthly to discuss people’s care and gain their feedback. The manager had implemented a relative meeting and was due to hold this with relatives. When we spoke with relatives they told us they were confident to raise any issues with the manager or staff and that these would be addressed. However, some staff told us they did not always feel comfortable raising issues with the manager as they felt they were too busy or were not approachable. Some staff told us they would raise any concerns with another senior member of staff but did not feel they would be addressed.

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. The manager had started holding regular staff meetings to build inclusivity and involvement of staff. The manager had also started discussing with staff having champions for certain roles such as IPC champion. The manager had tried to promote equality and diversity by making staff aware of additional training they could complete on this.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider did have reporting systems to monitor its services however, the manager told us they had not received training on using this system. The manager relied on doing their own paper-based audits and raised issues by email with the provider. The manager had not implemented an action or improvement plan with timescales for completion on areas that needed improvement. The manager was unable to evidence they had a system in place to review accident and incident and identified themes for action. The managers governance processes had not identified or addressed the issues with staff training, medication competency, medicine audits or the lack of clinical audits being in place for the tracheostomy emergency kits. Where the manager knew of risks regarding fire doors not being alarmed, they had not taken action to mitigate the risks until this was highlighted to them on inspection. We were not assured governance processes were robust, effective or enabling the provider to have full oversight of the service.

This demonstrated a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Good governance.

Following the inspection the provider was able to show evidence they had put measures in place to ensure the fire doors were alarmed with a magnetic lock driven by the fire alarm system.

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. Staff at the service worked closely with other healthcare professionals to provide care and support to people. This included regular reviews from their GP and practice paramedic. Senior staff were involved in health reviews for people to ensure they continued to get the support they needed. The manager had worked closely with the local authority to investigate a safeguarding concern. People were supported to access the community and local facilities.

The provider did not demonstrate how they shared continuous learning with the service. The manager had implemented regular staff meetings to share feedback and learning with staff. However, systems to monitor and ensure staff training was kept up to date was ineffective with training needs not always being completed in a timely way. The manager had started to implement workshops to upskill staff and following the inspection was proactive in sourcing tracheostomy training.