The Bungalow

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 service was in breach of legal regulation in relation to the governance at the service.
 

This service scored 46 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The culture of the service did not consistently support the delivery of safe, person-centred care. Systems and processes focused on recording information but were less effective at promoting learning, understanding people's experiences and driving improvement. Staff frequently referred to the area where the home is based as a "compound", this reflected an institutional culture.

Leaders had not ensured staff always worked from accurate information or that risks and concerns were used as opportunities to improve outcomes for people. As a result, shortfalls in care planning, risk management and the environment were not always identified or addressed.
 

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

We identified breaches of the legal regulations and concerns in the areas of safe care, person centred care and governance. Leaders had not maintained effective oversight of the quality and safety of the service. Audits and monitoring processes failed to identify or address a number of concerns relating to care records, incident management and personalised care. For example, management reviews of incidents were often generic and did not identify triggers, themes, learning opportunities or preventative actions.

However, staff spoke positively about the leadership of the service. They told us the registered manager was approachable, supportive and listened to their views.
 

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

The service had not demonstrated a culture where concerns were consistently identified, raised and acted upon. Incidents were not always appropriately reported by staff or recognised through management oversight. This reduced assurance that people and their relatives would be informed of concerns promptly and receive explanations or apologies when required.
 

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.

Policies and procedures were in place for workforce equality, diversity and inclusion to enable a more equitable and inclusive organisation. Staff and leaders did not raise any concerns about how the serviced worked towards an inclusive and fair culture by improving equality and equity for people who work for them.
 

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.

Governance systems were ineffective. Audits and quality assurance processes failed to identify and address significant concerns relating to incident management, care records, environmental safety, confidentiality, infection prevention and control and food safety. For example, audits failed to identify all incidents involving people using the service and environmental checks did not result in a timely response to the maintenance and safety concerns found during the inspection.

Leaders took action to address some concerns during the inspection. However, governance and oversight systems had not been effective in identifying and responding to issues in a timely manner. As a result, several concerns relating to the quality and safety of the service had not been addressed, placing people at risk of poor outcomes.
 

The provider worked in partnership with families, representatives and professionals involved in people's care.However, leaders had not consistently developed wider links with community organisations to enhance opportunities for people.

As a result, opportunities to broaden people's access to community activities and experiences had not always been fully developed, which reduced opportunities to achieve positive outcomes.
 

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.

At the time of the assessment, we identified multiple concerns that had not been recognised or addressed by the provider. Systems to support learning, improvement and innovation were not operating effectively. Repeated concerns remained unresolved and quality assurance processes had failed to identify deterioration in the quality and safety of the service.

Processes intended to monitor and improve the service were not effective in driving improvement or ensuring people consistently received good quality care. Audits and governance systems did not identify where action was needed, and the provider was not consistently meeting the fundamental standards of care. Although action was taken in response to concerns identified during the assessment, we could not be assured improvements would be sustained or embedded over time.