78 Hoylake Crescent

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.

The last rating for this key question was good. At this assessment the rating has changed to requires 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.

We identified breaches of legal regulation relating to good governance.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People living at the service did not always feel there was an inclusive or friendly culture. Comments from people included, “I just tow the line. Keep my head down and stay quiet” and “There is always disturbances going on and I do not feel it is a safe place to live.” We discussed this feedback with managers so they could talk with people about their concerns. Following our visit, the management team told us they had spoken with people to help provide assurances. They explained people did not always feel safe due to their mental health conditions.

Managers had failed to ensure the service complied with legal requirements. There was a lack of oversight which led to multiple breaches of regulation which placed people at risk of inappropriate and unsafe care.

The provider was a partnership. Both partners were involved in the day-to-day management of the service and 1 was the registered manager.

People using the service told us they did not always feel listened to when they spoke up. Managers told us they gave people opportunities to discuss their concerns. The provider had systems for staff and other stakeholders to speak up when they had concerns. Staff told us they felt confident raising concerns if needed.

The provider had systems to ensure workforce equality and inclusion. Staff were not discriminated against. Staff told us they felt they were treated with equity.

Managers told us they supported staff to celebrate their religion and culture. Staff were able to take time off or request flexible working patterns for religious needs.

The provider did not effectively operate systems and processes to monitor or improve the quality of the service. Managers undertook a range of audits. However, these had not identified where the problems were and there were no plans to make required improvements. For example, audits of the environment had failed to identify potential risks and poor infection control procedures. The recorded audits of hot water outlets showed that on each occasion they were tested all outlets were the same temperature and this was within safe ranges. However, we found hot water outlets were extremely hot. Therefore, the audits could not be relied upon as accurate. Audits of medicines management failed to identify issues with storage. Audits of staff recruitment, training and working hours had failed to identify potential risks.

The provider had failed to ensure records were appropriately stored, information was accurate or up to date. Some records were not available at the service. Records were poorly organised. For example, loose sheets of information about people, care records and medicines charts were left unfiled on the desk in the office. Where records were within files these were not always clearly organised.

Information within some people’s care records was not always accurate. For example, we found some referred to the wrong person, needs which had since changed or were unclear and generic.

Inaccurate records and incomplete audits increased the risk of people receiving poor care which did not meet their needs.

The provider’s systems for staff communication did not ensure adequate privacy. Staff told us they used a messaging service on their personal mobile phones to exchange information about people living at the service with each other and managers. This system was not secure because it involved staff members’ personal devices.

The provider did not always work effectively with external professionals. We received feedback from commissioners, the local authority where the service was located and the London Fire Brigade. These partners told us the provider did not always act on their feedback and questioned their findings when they identified concerns. They felt partnership working needed to be improved to make sure people received good quality care.

The provider did not always promote a learning culture. Staff were not involved in learning proactive strategies to support people’s mental wellbeing or learn from incidents.

Staff were required to undertake a range of training including online training modules. Records of completed training showed that some staff had completed essential training courses in less than 5 minutes. These records indicated the training courses had not been completed in the way they were designed and there was a risk staff did not have the required skills or knowledge to provide safe and effective care. The provider’s audits had not identified this risk.

Staff told us team meetings included short training sessions which they found useful and supportive.