New Boundaries Group - 329 Fakenham Road

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

Governance systems were not effective in ensuring compliance with regulations. The quality and safety of the service had not been effectively assessed and monitored, systems to ensure risks had been assessed and mitigated were ineffective. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Governance systems were not effective in overseeing the quality of the service. There were no provider level audits and monthly manager audits had not been carried out on a regular basis either. The manager audits that had been carried out had been ineffective at identifying the issues within the current service. No systems were in place to monitor risk within the service. For example, staff carried out regular monitoring in areas such as food, fluid intake, and bowels but no system was in place to review these and identify concerns. Where actions had been identified as needed to be taken, for example from external fire and water risk assessments, there had been a delay in timely action to rectify these areas. Whilst records were stored securely there was no clear filing system in place. This meant information was difficult to access and could not always be provided at the time of our site visit.

The current manager was providing management cover to all 5 of the provider’s care homes. Staff and relatives told us they felt the manager was supportive and approachable. However, they raised concerns about them being “stretched”. Staff told us there had been a lack of strong leadership and management in the service. One staff member said, “We just need some proper structure". The nominated individual, who is responsible for supervising the management of the service on behalf of the provider, told us they recognised changes needed to be made in the management structure. They provided us with a plan on how they would be addressing this. This included appointing care staff to a senior care assistant position to oversee and provide guidance within the service.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.