New Villas Office

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.

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 regulation in relation to good governance. Specifically, the provider's quality assurance systems were not always effective to monitor, assess and improve the quality of 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.

Whilst the provider had a vision statement and a strategy for the service, these were not consistently understood, implemented and shared. The provider did not always understand the challenges and the needs of people and their communities.

Management were not clear in their understanding of supported living and the expectations people might have for progress and development in their support. This was evidenced in support plans which lacked clear goals and monitoring of outcomes.

The provider's vision and values were not understood and shared by people and the staff who supported them. The culture of the service did not empower people to understand and act upon their rights as ordinary citizens living in their own home. The environment, particularly in communal areas was not always suitable for the people who lived there in relation to the décor, which might not have taken into account people's sensory needs. There were also some over restrictive policies relating to visitors, such as specific visiting hours and free movement.

There were inconsistencies between addresses in relation to accessible information and escalation of incidents, which did not demonstrate shared culture.

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.

During our inspection it was not always clear that management had an accurate understanding of supported living. There were inconsistencies between addresses which did not demonstrate a

cohesive service or thorough oversight across the entirety of the service. For example, we saw some really good practice in relation to involving people at resident meetings and

communication of outcomes at one address, but this was not evident at another address. One site was not presented like the home of individuals, with the environment pertaining more to

a care home. Leaders did recognise this once brought to their attention.

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

Staff have directly contacted CQC to express concerns with regards to care planning. The people speaking up expressed they have not felt listened to by management and their own knowledge of people's needs have not been listened to.

There was a clear and thorough whistleblowing policy in place which staff we spoke to were familiar with. Staff told us they understood how and where to escalate concerns if needed and this is apparent in communication CQC has received.

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 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 recording of incidents and outcomes was not always complete. It was unclear who had oversight of these and there were inconsistencies across the addresses regarding escalation to senior staff. There was not clear learning recorded in relation to such events. Incidents found in individual care records did not always match with service records of these.

Although there were audits in place to monitor the quality of the service these were not always effective. We found that the care records audits were not carried out consistently as these have not identified areas for improvement. This includes the use of outdated and unsuitable language and the fact that care plans and risk assessments were not always updated in a timely manner. The provider had also not identified through their governance systems that further improvements were required to demonstrate compliance with good practice regarding the provision of a supported living service and compliance with guidance such as CQC guidance, Right support, right care, right culture.

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.

We saw evidence of a transition plan that was not person centred and did not involve all relevant agencies. The move was also delayed due to failure to plan for annual MOT of the service minibus, meaning transport was not available when needed.

We were contacted by staff following our on site assessment who raised concerns about the move of another person, expressing that planning had not involved specific support staff and their input was not recorded or listened to..

This lack of cross service working does not demonstrate a learning from previous such moves and problems that arose in relation to them. Lack of open communication with staff and other professionals demonstrates that partnership working was not always effective.

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,outcomeand quality of life for people. They did not always actively contribute to safe, effective practice and research.

Approaches to continuous learning and improvement were not consistent throughout the service. Feedback wassoughtand recorded in some parts of the service though communication of outcomes was not clear. People were encouraged to share their ideas and leaders were open to suggestions, though we saw no signs of creative or innovative practice being put in place. Lack of collaboration across all parts of the service led to inconsistencies in equity of experience.