Mr 'C's

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 Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to people’s safe care and treatment, person-centred care, safeguarding, good governance and staffing.

This service scored 36 (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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Systems for gathering and responding to feedback from people, relatives and staff were ineffective and action had not always been taken when concerns were raised. Relatives reported responses to problems were not always helpful, and changes were not sustained. They were not kept informed about the welfare of their family member, or involved, with their family member in planning and reviewing their care.

Systems in place to monitor the quality and safety of care were ineffective. This meant the provider did not have an understanding of the issues impacting on people using the service, placing them at risk of poor care.

Staff did not receive the support they needed to provide safe care. They did not receive adequate training or individual face to face supervision, and there were no staff meetings. This meant opportunities for staff to engage in learning, reflection, and contribute to the development of the service were limited.

Although people and relatives were positive about the kindness of staff supporting them day to day, the provider did not demonstrate a positive, compassionate, listening culture that promoted trust and understanding between them and the people using the service. The service lacked a person-centred approach and did not adequately uphold individuals’ rights.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The provider failed to establish and implement a robust and effective governance framework, which meant key shortfalls, such as inadequate risk assessment, recording, environmental safety and staff support, were not addressed. As a result, risks within the service were not well understood or managed, increasing the possibility of unsafe and poor-quality care.

We were not assured the management team at the time of the assessment possessed the necessary skills and knowledge to effectively lead and oversee the service. The provider told us they had identified this prior to the assessment. Despite this they continued to delegate responsibility to them for the day to day running of the service.

Staff feedback also highlighted concerns about communication, lack of staff meetings and supervision. While some staff described supportive leadership, leadership arrangements were not consistently effective in driving good outcomes for people.

People did not always feel they could speak up and their voice would be heard.

The service did not always create a culture where people and staff could confidently raise concerns and be assured they would be acted on. Oversight of incidents, complaints and safeguarding concerns was ineffective, and concerns were not always identified, reviewed or escalated appropriately.

Staff feedback indicated communication between the management team and staff was inconsistent. Relatives described situations where they had raised concerns, but no action had been taken. These issues meant people and staff could not always be assured their concerns would result in meaningful change, and improvements were not consistently embedded following feedback.

Leaders described open-door arrangements and alternative routes for staff to raise safeguarding concerns. People generally knew who to speak to if they had concerns, and feedback from people about frontline staff was mostly positive.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Workforce systems were not sufficiently robust to ensure staff were consistently supported, developed and equipped to meet people's needs effectively. Significant gaps in mandatory training records were identified, induction processes were inconsistent, and some staff were not included on training monitoring systems. As a result, the provider could not demonstrate all staff had the necessary knowledge, skills and competencies to safely support people with diverse and complex needs.

Feedback regarding workplace culture was mixed. While some staff reported positive teamwork and support, there was limited evidence of effective workforce oversight. The lack of regular supervision, staff meetings and competency monitoring reduced opportunities for staff to reflect on practice, raise concerns, access professional development and ensure their experiences were understood. These weaknesses also limited the provider's ability to identify and address potential inequalities within the workforce.

The service demonstrated some positive aspects of staff support, with staff describing a supportive team culture and an example of reasonable adjustments being made for an employee returning to work following injury. Some staff had also developed strong, compassionate relationships with people using the service and were committed to providing person-centred care.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service did not have effective governance, management and oversight systems. Quality assurance processes failed to identify many of the serious concerns found during the assessment. Audits could not be relied upon to identify risks or drive improvement, environmental audits failed to identify significant safety concerns and actions identified through previous audits had not been completed. Care records were incomplete, risk management was ineffective and confidential records were not always stored securely. Leaders lacked an accurate understanding of service quality and associated risks, and there were concerns significant safeguarding events may not always have been reported appropriately.

The provider 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 or collaborate for improvement.

The service usually worked with partners and community organisations to support people's wellbeing. Leaders described effective relationships with health and social care professionals, including community alcohol services, housing services, social workers and healthcare teams. There was evidence of regular contact with the local authority quality improvement team.

Some people were supported to maintain community connections, attend local events and access services that reflected their interests and needs. Community organisations, including local faith groups and veterans' representatives, visited the service and helped reduce isolation for people who had limited social support. These partnerships helped some people achieve positive outcomes and remain engaged with their local community.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The service did not have effective systems in place to learn from incidents, monitor quality or drive continuous improvement. Although leaders were able to describe some lessons learned from individual events, processes for reviewing and analysing accidents, incidents and safeguarding concerns were inconsistent and ineffective.

Accident and incident reviews were not always completed, meaning important opportunities to identify risks, implement preventative measures and improve care were missed. Significant incidents were not consistently escalated, investigated or used to update care plans and risk assessments, which increased the risk of repeat incidents and reduced the service's ability to respond to changing needs.

Quality assurance processes were also ineffective. Audits failed to identify serious and ongoing concerns relating to medicines management, care planning and safety. As a result, issues remained unresolved and leaders did not have reliable oversight of the quality and safety of the service.

There was little evidence of a structured approach to quality improvement, innovation or engagement with external initiatives to support service development. Opportunities to analyse trends, share learning and improve outcomes for people were routinely missed. This meant the service could not demonstrate a culture of continuous improvement, resulting in missed opportunities to enhance safety, quality of care and people's experiences.