Walsingham Support - 1 Ashley Close

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 leadership,managementand 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 inspection, this key question hasremainedrequires improvement. This meant the service 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 continued breach of the legal regulation in relation to good governance.

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 did not demonstrate a clear shared vision, strategy and culture which placed people’s experience of care at the centre of the service. People had not experienced consistently positive, person-centred care.

The registered manager had recently joined the organisation and had taken proactive steps to enhance the quality of care provided. Family members acknowledged noticeable improvements and positive changes within the service. Staff expressed high regard for both the registered manager and the company. One staff member noted, "The registered manager communicates effectively with us and ensures we are kept informed about developments within the service. Their focus is on implementing positive changes."

Nonetheless, the provider lacked adequate oversight of the home, as concerns were identified during the assessment that the provider was previously unaware of. For example,staff told us they read people’s care and support plan but none had recognised issues regarding inaccurate documentation, which posed a potential risk of harm.

The management arrangements had not been stable or robust as there had been eight managers employed in the last 2 years and this was confirmed by relatives. This meant there was a lack of continuity of care.Relatives told us getting information and having good communication at times had been challenging. However,there was a new registered manager who had started to embed improvements. Since taking up the role, the registered manager has prioritised staff recruitment and retention, viewing this as the foundation for driving ongoing improvements within the home. At the time of the assessment there was no deputy manager in a permanent position which placed extra pressure on the management of the home.

Staff described the registered manager as caring,knowledgeable and approachable and they told us they could see the registered manager was committed to driving change. One staff member said,“We have an unrestricted access to management, there are various channels of communication, everyone is happy to lend a hand and when something is reported there is always a quick response and solutions eventually found”.

The provider had systems for speaking up and staff were familiar with these.The provider had whistleblowing policies and procedures in place. Staff told us they would raise concerns if they felt they needed to. There had been no concerns raised since the new registered manager started.

The provider understood their responsibilities under the duty of candour. The duty of candour is to be open and honest when untoward events occur.

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. Staff felt the provider valued diversity within their workforce and people were supported by a diverse team. Overwhelmingly, the feedback from staff was they felt supported by the registered manager. Staff told us there were no concerns regarding workforce equality,diversity and inclusion. Comments included, “There was no discrimination” and “There is diversity and inclusion of everyone’s voices. Each voice is given the necessary importance and I think it’s fair.”

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 quality assurance and governance arrangements in place were not effective in identifying shortfalls found at the service as part of this assessment. 

For example, internal audits had not identified risks found with managing medicines. People’scare plans and risk assessments were not up to date despite staff recording they had completed reviews and there were no effective systems for monitoring accidents and incidents.

The new registered manager was unable to provide us with investigation reports for safeguarding concerns,and they were unable to confirm if the local authority had been informed. Yet,the provider had their own governance processes,but these systems had not detected the issues we found. The provider has taken action to ensure there is more robust procedures in place for managing safeguarding concerns. This information has been shared with the local authority

A Service Improvement Plan had not been devised and implemented with the support from the local authority. The purpose of a Service Improvement Plan is to proactively identify and monitor performance, address weaknesses in service delivery and recognise areas for improvement.

The registered manager told us they were planning to develop more partnerships with local community groups which would enable people to attend more local events. They recognised this was an area where they wanted to develop more robust relationships to ensure people had access to a wide range of support and activities..

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The lack of robust quality monitoring meant there was no record of learning lessons when things went wrong,and monitoring had not picked up the concerns regarding the lack of reporting safeguarding concerns.

The registered manager and senior staff were open and transparent during the onsite visit and explained they were committed to embedding the change needed to ensure people received good care.

The registered manager was focused on ensuring staff had the necessary skills to care for people. Since they had started at the home, they told us they had focused on ensuring staff training was up to date. Staff told us the registered manager was focused on driving improvement.

Staff told us they received regular support from the managers through supervision and an annual appraisal and they felt there was good channels of communication.