Archived: 58 Acton Lane

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 inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant we identified shortfalls with the governance of the service. The model of care was not always in line with current best practice guidance right support, right care, right culture. There was a lack of effective auditing processes and management oversight which has resulted in a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion and engagement. Management promoted people’s equal rights and ensured there were no workforce inequalities.

The feedback we received from staff about the interim manager was positive. Individual staff supervisions and team meetings were used by the service as a platform for staff to raise concerns and reflect on areas of improvement and professional development needs. However, leadership did not always have the skills, knowledge, experience and credibility to lead effectively. There was not a registered manager in post, and we were unable to verify training and qualifications held by the interim manager because this was not recorded on the staff training matrix.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We reviewed the ‘Service Action and Improvement Plan’ which indicated areas such as staff recruitment retention, community integration and quality assurance as priority for improvement and desired outcomes. However, the service did not always have clear systems of accountability and good governance to identify and drive improvements at the service. There was a lack of auditing processes relating to medicines optimisation, care planning and building safety and maintenance. The absence of a registered manager for over 3 years contributed to a lack of structural clarity within management and the oversight of daily operations lacked defined roles. We found action had not always been taken to ensure all commissioned hours had been allocated to ensure people received staff support with their social activities and needs. Recommendations from external audits were not followed up on to drive improvements within the service. This is a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service 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. For example, commissioners told us they were not always informed when people’s care and support needs had changed. This can have an impact on the quality of care being provided and meant that commissioners may struggle to ensure that support was still appropriate, leading to potential gaps in care, unmet needs and risk to a person’s wellbeing.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice, this compromising the safety of the people who live at the service.