Affinity Trust - South West

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. 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 provider was in breach of the legal regulation relating to good governance.

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 provider had a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider had a clear set of values and had engaged staff in understanding and embedding these. A review of the service’s culture had been completed, with actions identified for improvement. Staff spoke positively about the people they supported. Most staff described a supportive team environment, however, feedback on morale was mixed. Comments from staff included, “Generally quite happy,” and “The team is happy, we communicate, we support each other, we are a good team,” and “Very negative at the moment.”

The provider did not ensure they had leaders at all levels who fully understood the context in which the provider delivered care, treatment and support. Whilst they embodied the culture and values of their organisation, managers did not always have the knowledge or understanding to ensure the service provided safe and effective care in line with best practice guidance. For example, there were shortfalls around best practice in care planning, assessing risk and people’s mental capacity.

The registered manager also had responsibility for another of the provider’s services. They had not been overseeing Affinity Trust South West whilst another manager was in post. This manager left prior to our assessment, and during our assessment, the registered manager had resumed oversight of the service. They responded promptly to our concerns and demonstrated leadership in addressing the issues we identified.

Prior to our assessment, the provider deployed additional management support to strengthen oversight in services where concerns had been identified by the local authority. They assured us that further resources would be introduced to support the registered manager and improve governance however these had not been embedded. During the assessment, the management team were transparent, receptive to feedback, and took immediate action to address concerns raised.

We received mixed feedback from people’s relatives regarding the management of the service. One relative told us they thought there was not always, “Good communication between management and staff team.” Other comments from relatives included, “I know who the manager is, there does seem to be a lot of them” and “It’s had a high turnover [of managers], lots of them.”

We received mixed feedback from staff relating to how supported they felt by managers. One staff member told us, “There’s no support that I’m aware of, I can go weeks without speaking to my manager.” Another staff member told us, “Yes I do feel supported, I can pick up the phone and ask for help from my line manager.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt confident if they raised concerns, these would be responded to by the management team.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff felt they were treated fairly and equally.

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

Systems and processes to assess, monitor and mitigate risks relating to the health, safety and welfare of people had not been fully effective. The provider’s systems had not identified all the areas for improvement detailed in other sections of this report. The provider had an action plan in place for one of the services, this had not identified all of the concerns we found during our assessment.

We found improvements were needed to ensure individual risks of harm for people were identified and mitigated, medicines were managed safely, staff received appropriate training and people received consistent person-centred care.

The management team were transparent and receptive to our findings throughout the assessment and undertook action to make improvements. The provider acknowledged the existing systems and processes needed strengthening. They gave us a detailed plan of the action they had taken to address this.

Although the provider understood their duty to collaborate and work in partnership with other. We received mixed feedback from professional relating to the support people received.

We received concerns from the local authority prior to our assessment and some ongoing concerns; the provider told us they were working with the local authority to resolve these.

One professional told us the manager had been, “Proactive” in supporting a person’s wellbeing and “Liaising effectively.” They went on to say the manager had been, “Forthcoming with ideas for making improvements.” Another professional told us staff and managers they had spoken with were, “Responsive and professional.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe and effective practice. A lack of effective oversight and governance had impacted on their ability to do this. The provider gave us assurances regarding the additional systems and measures they had put in place.

The provider had undertaken a ‘lessons learnt review’ following concerns being raised relating to 2 of the supported living services. This resulted in a detailed action plan that was shared across the organisation for implementation. This was to ensure that organisational learning was embedded to reduce the recurrence of the issues identified.