Balby

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

The provider had several overarching governance systems in place; however, these had not been effective in identifying some concerns. Due to alleged concerns regarding the staff team, an interim management and staff team had been implemented. The provider was implementing new governance systems at the time of our inspection.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the time of our inspection staff told us the morale within the team was low. One staff said, “I’ve just noticed a change right now in the service. I feel a bit lost.” Time was needed to ensure the culture amongst the team could be improved.

Whilst the service had clear systems, visions and values in place, staff had not always followed these. The provider had recently recognised a closed culture within the staff team. The provider had taken action at the time of our inspection, to rectify this concern, such as introducing an interim senior management and staff team.

At the time of our inspection interim senior management teams were in place, to oversee the day-to-day operations of the service. Staff told us they were unclear about the current changes in the service. Staff did not raise any concerns to us about the registered manager. One staff said, “The manager has always been very approachable and fair.”

The provider had recently been alerted to poor practice in the service and had taken immediate action to address concerns. This included, implementing new staff, undertaking spot checks, completing well-being checks for people, completing regular serious incident meetings and liaising with the local authority. The provider had not notified us of all allegations of abuse, we found a concern which we had not been notified about or reported to the local authority. However, this concern had been recognised and a notification was subsequently submitted to us at the time of the inspection. We informed the local authority of this concern following our inspection.

Staff were involved in regular staff meetings and supervisions, records of these did not evidence staff had any concerns. Staff told us they understood their responsibilities to report concerns. One staff said, “I have supervisions every 6-8 weeks. I find them useful; I can raise issues and am listened to.”

The service had clear whistle blowing procedures, which were available throughout the service and the provider also had an internal whistle blowing hotline. The provider told us staff had failed to whistle blow on poor practice and this was being worked through with staff.

All staff had been supported with their professional development. Staff had received robust training and opportunities to develop their knowledge and skills.

Policies and procedures were in place to promote equality and diversity. However, at the time of our inspection, staff told us they did not feel valued as they had not been kept informed about the current changes in the service.

Due to recent concerns within the service, the provider told us what action they were taking to ensure there were new robust systems in place. The service was being overseen by the nominated individual and senior quality leads.

The provider had auditing systems in place, which included audits of the safety and quality of the service. Whilst these audits had been effective in ensuring the environment was safe, records were robust and staff were suitably recruited and trained, they failed to recognise medicines and safeguarding concerns. The provider was undertaking actions to address this, including having a senior operations manager undertake shifts within the service and speaking to all staff. Continuity plans were in place and detailed what action should be taken in the event of an emergency.

The managers had not always collaborated with partners, to ensure good outcomes for people, they did not report all safeguarding concerns to the provider, as per their policy.

During our inspection the provider and senior management team were open and honest and provided us with all information we required, however we did find 1 incident which had not been reported to the local authority as required.

External agencies were visiting the service to undertake safety and well-being checks. The local authority was working closely with the staff and told us they were providing information in a timely way and had been open and honest.

The interim management team were working closely with the local authority to ensure people were safe.

As staff had failed to whistle blow and several areas of the home was performing well, the provider told us they felt that the home appeared to be well led and safe. The provider recognised further governance systems were required to ensure closed cultures do not emerge.

At the time of our inspection the provider had implemented various systems to ensure people were safe. This included a voluntary embargo on new admissions, 3 weekly serious incident reviews, sourcing an independent external review of the service, senior managers conducting shifts in the home and well-being checks.