Arncliffe Court Care 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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.At our last inspection we rated this key question requires improvement. At this inspection 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 provider was in breach of legal regulation 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 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. The provider did have policies in place in line which were in keeping with best practice guidance however, they were not always relevant or followed. For example, the providers service user guide was designed for care at home service rather than a care home which meant people coming into Arncliffe Court Care Home did not have appropriate information to make an informed decision about the care they will be receiving at the home.

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. For example, concerns identified with the quality of care issues previously known to the provider were identified during this inspection. Concerns such as poor medicine management, care records and governance of the service. The registered manager was unaware of some of the concerns we raised during our inspection, and the associated risks. For example, when we provided feedback about the management of people’s distressed behaviours, they did not understand the impact of staff not having access to the appropriate information or detailed strategies.

There was limited evidence of ongoing support and development available to staff, to ensure they could support people effectively. We received mixed feedback from people and their relatives about their experience in delivering care. A relative told us, “There is a broken plug and cobwebs behind the bed. The shelf under the sink has been broken for a while although I have reported it, nothing seems to be done. Staff tend to congregate outside [Name] room on the patio to smoke which is not nice. I had to phone the home with my mobile standing outside waiting to be let in for 10 minutes until they answered.” However, one person told us, “I have told them about my health, and they check if I am in pain and they help me. I feel happy here.”

People did not always feel they could speak up and their voice would be heard. Although staff knew how to raise concerns, they did not always feel they were listened to. A staff member told us, “They [management] are not approachable. Couple of staff members put complaints in and nothing happened.” Information such as the Whistleblowing policy was available to staff to guide them on how to raise concerns.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by promoting equity for people who worked for them. Staff told us they were able to ask for reasonable adjustments to be made to their working patterns for specific needs, for example, to incorporate family commitments.

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. Improvements were needed to ensure the governance was effective and robust, including the monitoring of the quality-of-service provision. The provider did not have effective checks in place to identify and drive improvements. For example, the registered manager failed to review care plans to ensure they accurately reflected people’s needs. The registered manager did not have systems in place to review environmental walk arounds and failed to identify or rectify the issues we found at this inspection relating to the environment. The registered manager did not have effective or consistent systems in place to review incidents, accidents or significant events to minimise the potential for harm. Neither the registered manager nor the provider checked people’s assessments were completed to ensure they were accurate and reflective of their needs. For example, a recent pre-admission for a person moving to the home had not been completed which meant the provider had not checked if they could meet the person’s needs before admission. This lack of oversight put people at the risk of avoidable harm.

Where people had been assessed as requiring a Deprivation of Liberty and Safeguards (DoLS) for their safety, we found they had not always been completed or had expired which meant people had restrictions imposed on them unlawfully.

The systems in place to ensure people’s medicines were managed safely were ineffective. The provider did not have effective systems to monitor medicine stock levels or identify when supplies were running low. Systems to ensure staff had the skills to safely administer medicines were not robust and we found competency assessment had not always been undertaken in line with best practice guidance.

The provider had failed to identify the registered manager lacked the ability to critically review practice and was unable to consider where practices may need to be improved. The provider did not have effective oversight of the service and they had not identified where the service was failing to meet legal requirements. We found the quality and safety had deteriorated since our last inspection visit.

The provider did not always demonstrate they understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information in a timely or effective way with healthcare partners to ensure people received positive outcomes. For example, when one person’s modified diet was changed by an external health professional, the provider failed to update the information in all care records to ensure the person was supported with the correct diet. We identified instances where the person was given a diet inconsistent with external health professionals’ advice, placing them at risk of aspiration or choking. A relative told us they had been worried about their loved one’s deteriorating health and weight loss. It was agreed with the provider they would update the family weekly; however, this was not done. The relative told us, “They [management] told me, we can’t be phoning every individual up about things.” We found the registered manager had failed to ensure recommendations made by other healthcare professionals were followed such as wound management, falls management nor did they seek advice for concerns people presented with such as seasonal affective disorder (SAD).

The provider did not demonstrate a focus on continuous learning, innovation, or improvement across the organisation or within the local system. Creative approaches to promoting equality of experience, outcomes, and quality of life were not encouraged. The provider did not actively contribute to safe, effective practice or research and lacked systems to promote ongoing learning and improvement across the service. Systems to review care plans were not effective as the provider had not identified errors and inconsistencies we highlighted during our assessment. Leaders failed to recognise and reinforce safe and effective practice, limiting their ability to drive continuous improvement. The provider did not consistently seek or act on feedback from external partners. Although people’s relatives were informed of incidents when they occurred, people were not actively involved in reviewing any concerns, accidents, incidents, nor in planning to prevent recurrence. This demonstrated the providers governance systems were ineffective in promoting learning, driving improvement, or ensuring good-quality care was provided to people after an incident. As a result, people were placed at risk of avoidable harm because we were not be assured needs were accurately assessed or care was planned in line with best practice.