De Bruce Court

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 provider was in breach of Regulation 17 because governance systems had not operated effectively to assess, monitor and improve the quality and safety of the service.
 

This service scored 61 (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.

At the time of our assessment, the registered manager was absent from the service, and an interim manager was leading the service day to day. The provider had not demonstrated that interim leadership arrangements were supported by effective provider-level oversight. We found no clear action log, limited evidence of lessons learned from incidents, unclear health and safety audits, and delays in completing actions to reduce environmental risks. This showed the provider’s systems had not ensured a consistent shared direction for safe, high-quality care during a period of leadership change.

Staff gave positive feedback about working at the service. A staff member said, “We are a great team, we work together.” Another staff member said, “I Feel well supported. I’d go to [managers] if I did, no problem.”
 

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. 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.

At the time of our assessment, the registered manager was absent from the service, and an interim manager was leading the service day to day. The interim manager demonstrated awareness of some improvements needed. However, we were not assured the provider had ensured they had sufficient support, oversight and structured handover arrangements before taking on this role. This contributed to gaps in the management of known risks, including environmental risks and learning from incidents. Provider-level oversight was not effective enough to ensure risks were consistently identified, monitored and addressed.
 

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always have effective governance systems to assess, monitor and improve the quality and safety of the service. Responsibilities, accountability and oversight arrangements had not ensured risks were identified and acted on promptly.

Quality assurance systems were not effective because we found shortfalls in premises safety, risk management and learning from incidents. There was no evidence of an action log or documented lessons learned from incidents. Health and safety audits were unclear and lacked enough detail to show how risks were being monitored and reduced.

Stronger oversight was needed to ensure environmental risks were fully addressed and that people with behaviours that may challenge were kept safe and supported. Actions from incident analysis were not always timely, and ongoing monitoring needed to be strengthened. The interim manager was aware of the improvements needed and had started work to address these shortfalls.
 

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider showed a willingness to learn and improve and acted on concerns we raised. However, learning and improvement were not always timely or embedded well enough to reduce known risks to people.Some changes had started before our visit to reduce risks to people. However, these actions had not been completed quickly enough, given the known risks and the need for robust provider oversight.

The provider was committed to improving the service and had started to strengthen governance processes. These improvements needed to be embedded and sustained to ensure risks were consistently identified, monitored and acted on.