Sense 12 Oakfield Road

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 requires improvement. At this assessment the rating has remained 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 legal regulation in relation to good governance at the service.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff shared positive feedback in relation to the culture and morale at the service. Staff told us they felt supported by the management team and there was a positive culture amongst staff. Staff told us they had daily handovers, regular meetings and supervision. Staff demonstrated an understanding of the provider’s vision and how this translated into the delivery of person-centred care and support, which we observed during our inspection. These shared values were reflected through our conversations with the management team and the staff we spoke with.

We saw records of several compliments from family members, professionals and visitors to the home had been collated over the last year and they consistently praised the work staff do by noting their professionalism, helpfulness and kindness.

Although leaders had the experience, capacity and capability, the organisational vision was not always delivered, and not all risks were well managed.

Some risks were not consistently well managed at this service. This is a repeated concern from the previous inspection and meant risk management was not fully implemented. There have been 3 changes in management in the last 4 years at this service. The newly appointed manager had only been in post a few weeks when the inspection took place. The manager told us they felt well supported by the organisation. The provider told us they had systems in place to support the recruitment and development of leaders. They told us they encourage managers and deputies across the organisation to support each other. They have quarterly area meetings, themed workshops and feedback sessions which they felt work really well. They told us they were committed to supporting managers across the organisation.

Despite the concerns identified we found leaders to be open and honest and committed to address the shortfalls we found. They quickly responded to concerns and provided reassurance about people’s wellbeing and safety.

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

Systems were in place for staff to speak up. Staff were able to speak with the management team. The provider informed staff of their whistleblowing policy and procedures during their induction period. Staff told us occasional meetings took place where they could speak up and the management team was approachable.

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. They provided a range of training for staff and, where possible, opportunities for staff to progress their careers.

The provider promoted equality and diversity within the workforce and ensured staff were treated fairly and with respect. Staff spoke positively about how they were supported in their roles and felt their individual diverse needs were supported. Staff shared with us how the management team had supported them in their individual circumstances and provided support in both their personal and professional lives. The provider had policies in place which meant staff were recruited fairly, seeking a mix of backgrounds and skills that would meet the needs and enhance the lives of the people they supported.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not consistently act on the best information about risk, performance and outcomes.

At our last inspection we issued a warning notice due to concerns related to good governance and the oversight of risk management. At this inspection whilst some improvements had been made, the governance of the service was still not sufficiently effective. Systems and processes remained ineffective in ensuring compliance. For example, we found the oversight of health and safety was not robust. Audits and checks of the environment did not include the grounds of the supported living service. We saw a number of risks had not been identified or acted on. In addition, we found that although a new care planning system had been implemented there was information that was either inaccurate, not detailed or not completed. This meant guidance for staff to follow was not consistently robust and people’s care could not be fully reviewed if their care records were not accurate. We found a screening tool implemented for managers to have oversight of risk in relation to eating and drinking, failed to include checking if the persons guidelines were accurate. The provider has since taken action to address this, going forward reviewing guidelines will be part of the eating and drinking screening process.

The provider did act on all the concerns promptly, but this demonstrated a reactive service to risk, and a service where systems for the oversight of risk were not fully embedded.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The provider worked in partnership with other agencies to support people’s health and wellbeing and promote positive outcomes. Professionals provided positive feedback about the manager and staff team. A professional told us, “We have a good working relationship with the manager and staff at Oakfield Road, they are responsive and have a good stream of communication.” They went onto say, “All issues are addressed promptly and communication is robust.” Another professional told us, “Staff are professional and appropriate.”

The manager demonstrated how they ensured they kept up to date with current Health and Social care updates.

The provider told us they were committed to continuous learning, innovation and improvement but system in place were not always effective.

The provider was keen to demonstrate they were committed to continuous learning and improvement. They demonstrated an openness, and a willingness to learn from our feedback. However, systems for the oversight of risk management and actions from lessons learnt were not fully embedded.

The provider told us they were implementing a number of improvements across their quality assurance systems. A new electronic care planning system to help plan, record and coordinate care more effectively had recently been implemented. The provider had also restructured their quality assurance, and a new team had been developed to help drive improvement across the organisation. They told us mock inspections would be part of this process. They told us they were also improving the technology used by staff for accessing the electronic care planning system.

The provider told us manager’s from across the provider’s services met regularly to share learning from events and to support each other.