Douglas House

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, honest and fair culture.

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement. This meant the management and leadership were inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We found some governance systems were not always effective, and where audits had identified shortfalls, some action had not been taken in a timely manner. The service was in breach of legal regulations in relation to good governance.

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 service did not always have a shared vision, strategy and culture.

Staff were clear on the importance of focusing on supporting people as individuals, however, staff and people did not always think this was a shared focus from the provider.

We received mixed feedback in relation to the management team.

Some staff comments included, “I feel morale is very much down with the residents”, “I love this place, and they are not being mistreated, and it is not on the other carers or the managers it is the company. I don’t think they give two hoots, and it is all about cutting costs and the morale of the staff is being beat down.” Staff and relatives told us communication could be improved. However, people told us, “I think (manager’s name) will get things done but I don’t know if she will get the help and support from head office.” A relative told us, “There’s a new manager, and she seems keen and proactive.”

A staff member told us, “It is getting there now, it was very low, and we have had changes. (manager’s name) is lovely and is taking it on, I have seen a lift in residents and staff morale.”

The service had appointed a new manager, who had applied to become the registered manager with the Care Quality Commission. The manager was in the process of implementing changes within the service to improve the quality of care. The manager understood the context in which they delivered care, treatment and support. The manager had the skills, knowledge, experience and credibility to lead effectively. Throughout the assessment process, the management team were open and honest. A relative told us, “It wasn’t well led until the new manager arrived. It seems to be better when you call, it is usually her that answers the phone.”

The provider had processes in place for people to speak up, however, some staff and people felt their voices were not always heard.

Staff told us, “Yes, things have been passed onto management, but it is very difficult to see anything change, and they say they will look into it, but like everything else, nothing is coming back to us,” and, “I raised concerns at the last meeting, and it gets written down, but no-one gives feedback to you ever.” A relative told us, “I do speak up, it is not always acted on”.

However, other staff members told us, “On the 11-11 meetings, they do ask you how you are doing and if there are any issues to raise” and “Every month we have staff meetings and residents meetings, and we discuss how we can clear issues, and we tell them our point.”

The provider had systems to gain feedback from people, relatives, and staff, for example, through meetings, surveys, and an open-door policy. The provider also had an easy-to-read complaints process around the service.

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. A staff member told us, “We have a good team, and all of them are lovely, and I have no bad things to say, and new staff are welcome.”

Leaders promoted people’s equal rights and ensured there were no workforce inequalities. Some staff had not understood and implemented their training. The management team had recognised this, and additional training had been sourced to support people’s understanding and ensure safe practice.

The provider did have clear responsibilities and roles. However, the provider's systems, processes, and governance were not always effective in identifying areas of improvement. They did not always act on the best information about risk, performance, and outcomes.

The service had regular care plan and medication audits in place. However, these audits did not always enable the provider to identify where quality and/or safety were being compromised and to respond appropriately and without delay, putting people at possible risk of harm. For example, the provider’s care plan audit did not identify that people’s assessed needs were not always being met.

Whilst we did not identify anyone who had come to harm, this contributed to the breach of regulation in relation to good governance.

Heads of department and managers had regular communication to develop plans to implement changes. For example, we were told the provider was planning to change their paper-based care records to electronic. The leaders told us they felt this would provide better oversight and improve the quality of care. However, during our assessment, this system had not yet been implemented or embedded in the service.

The management team understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvements. We contacted partners to learn more about the service working in partnership. We did not receive any feedback.

The service did not always have a shared vision, strategy and culture.

Staff were clear on the importance of focusing on supporting people as individuals, however, staff and people did not always think this was a shared focus from the provider.

We received mixed feedback in relation to the management team.

Some staff comments included, “I feel morale is very much down with the residents”, “I love this place, and they are not being mistreated, and it is not on the other carers or the managers it is the company. I don’t think they give two hoots, and it is all about cutting costs and the morale of the staff is being beat down.” Staff and relatives told us communication could be improved. However, people told us, “I think (manager’s name) will get things done but I don’t know if she will get the help and support from head office.” A relative told us, “There’s a new manager, and she seems keen and proactive.”

A staff member told us, “It is getting there now, it was very low, and we have had changes. (manager’s name) is lovely and is taking it on, I have seen a lift in residents and staff morale.”