Archived: 1 & 2 Flax Cottages

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 inspection we rated this key question good. At this inspection 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 legal regulation 17 (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.

Leaders had not always ensured the culture at the service prioritised and fully explored the aspirations and needs of people.

The atmosphere was calm and welcoming but there needed to be more emphasis on person-centred care and outcomes. The acting manager and area manager were responsive to this feedback. We signposted them to resources such as Right Support, Right Care, Right Culture.

Staff understood and delivered compassionate care to people at all times, and were keen to facilitate positive outcomes for people who used the service. People felt safe and not subject to any discrimination or harm, although they were placed at higher risk due to the failings of the provider. They were valued by staff who respected them.

Policies and procedures had regard to equality and human rights, equity of care experiences, diversity and inclusion and the needs of people and their relatives.

The acting manager and area manager were open, approachable and had gained the support and trust of people who used the service, relatives and staff. They were working hard to recognise the areas for improvement and to make the necessary changes.

One staff member said, “You can go to [acting manager] with anything and they’ll stop and help you or talk it through.” The acting manager had introduced champion and leadership roles for staff, to ensure they had the opportunity to shape the culture.

Policies and procedures were in place to support the leaders deliver a more person-centred approach at the service.

Staff all felt they could raise concerns openly with the acting manager or area manager in a way that they had not felt able to do previously. They had access to external agencies and stakeholders, should they feel the service could not deal with their concerns appropriately.

One relative said, “It’s a good group of staff and you know they take on board anything you tell them.”

The provider had policies and systems in place to support people, relatives and staff to speak up if they needed. The acting manager had demonstrated through their approach to auditing, meetings and communications, that they could identify and act on matters that needed raising. They and the area manager had demonstrated accountability and actions in the brief time they had taken over the running of the service.

The provider valued diversity in their workforce. The acting manager understood the need to gain a better understanding or people’s diverse backgrounds and experiences and ensure that staff had a solid grasp of this. The acting manager also understood the benefits and challenges of a diverse workforce. Staff were well supported, with no discrimination or bullying. Staff were treated in an equitable way.

Governance, management and accountability arrangements had not always proved effective in ensuring the culture and environment were in line with recognised standards, such as Right Support, Right Care, Right Culture. There had been a range of provider-led audits of the service and a previous registered manager in place, but they had not ensured the service was meeting people’s needs as well as it should.

Walkarounds by senior leaders had not always highlighted overt issues that should have been an indicator of a culture needing improvement. For instance poor upkeep of some equipment, poorly maintained shared spaces, and a lack of person-centred care planning.

Systems and resources were available to ensure the acting manager and area manager had the time and facility to undertake ongoing audits and to ensure improvements were made rapidly.

The acting manager and area manager had made initial improvements but there was significant work to be done.

Staff were consistent in their understanding of people’s needs and wanting the best outcomes for people. They needed clearer leadership on how to enable and support people to achieve their aspirations and goals.

Relevant notifications and updates had been made to external partners, including CQC, as required. The provider committed to seeking advice and support as they reshaped the service to make it more person-centred.

The provider needed to do more to build external links with other organisations, so that the service was less at risk of becoming a closed culture in future.

People and relatives were generally happy with the service and their place in the community. They were comfortable and safe.

Staff were doing their best and took people out in the local area when they had the opportunity, but the service lacked the vibrancy and variety that better links would bring. Relatives were consistent in this area of feedback. One said, “The care is perfectly adequate, but he needs more social interaction.”

Feedback from external professionals was generally positive in terms of how the service engaged with them to review and meet people’s needs. There was recognition that since COVID-19 it had been more difficult to access day centres. The acting manager and area manager were committed were to exploring further options to build opportunities and partnerships in the community.

The service had some good external relationships and hoped to build on these and develop more as the culture changed. There was a service improvement plan in place, which the provider had developed alongside the local authority.

Staff had previously been at risk of becoming de-skilled, but the acting manager had introduced champion roles and was keen to ensure staff were empowered to take more responsibility for supporting people to achieve their goals.

The provider had not always focussed on continuous learning, innovation and improvement across the organisation and local system. The recent leadership changes had however seen improvements in reflecting on where there needed to be changes to training provision and staff support.

The acting manager had reviewed staff training records and taken steps to ensure those who were not up to date completed their mandatory training. They recognised the need to tighten up induction and training processes and had taken steps to do this. The acting manager had arranged regular team meetings and had supervisions in place with staff to give them the opportunity to explore their training and other needs. Likewise, these processes were used to communicate key messages and learning to staff.

The mixed standard of care records meant that performing meaningful audits and analysis of care records to identify themes was not always easy, and some opportunities for learning had been missed.