Norton Street

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• 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

We identified a breach of regulations in this key question in relation to good governance. We found significant gaps in audit, quality assurance and question of practice. The provider had failed to maintain oversight of quality and safety which contributed to the failures identified at this assessment. At the time of this assessment, the service was being managed by senior support workers. This was because the previous registered manager had resigned in June 2023 and the deputy manager had resigned in November 2023. Three new managers had been appointed since June 2023, but all had left within 2 months of starting to work at the service.

This service scored 54 (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.

Staff told us they felt there was a disconnect between the staff team at Norton Street and head office. Staff had a perception head office were not approachable and were over controlling. Comments included, “We’ve no manager to talk to and no communication with head office. We need a proper structure”; “Managers left as they didn’t feel supported by head office. Managers said when they want to implement changes always had to fight head office and they refuse these. There’s no direct contact from head office” and, “Head office want to be involved in everything and this causes conflict. It affects staff, not feeling supported properly or listened to.”

Whilst the provider had systems in place to formally capture the views of staff, such systems needed be operated in an open and transparent way. The provider needs to demonstrate how they are listening and responding to staff when genuine concerns are raised.

Staff told us previously they were able to confidently raise concerns with the manager or deputy manager. But since both had left, staff now felt there was disconnect between staff and leaders and staff had little confidence their concerns were being taken seriously by the provider.

In 2023 the provider completed staff survey, with mixed results. For example, 80% staff felt communication was OK and they felt able to give feedback. However, 65% of staff felt their views weren't taken forward. We spoke at length with the operations manager about staff engagement and they accepted more works needs to be done.

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.

Staff told us the lack of a registered manager and deputy means meant the burden of responsibility for audit and quality assurance had been left with them. However, this took them away from their core role of supporting people, and when coupled with general staff shortages, meant it was an impossible task.

There were systemic failures in systems for audit, quality assurance and questioning of practice. The last monthly medication audit on file was completed for the period 11/12/2023 to 31/12/2023. There was no audit in relation to medicines for the month of November 2023. No audits relating to the administration of medicines had been completed for the period 01/01/2024 to 28/01/2024. The provider had failed to ensure that medication audits were being completed monthly, as per company policy and governance of medicines in the service were not always effective. Other audits had been completed by a senior manager between 13 and 15 February 2024. These identified the same issues with cleanliness and IPC practice as identified at this assessment, demonstrating no meaningful effective action had been taken.

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.

Staff understood their responsibilities for reporting and recording of events within the service.

The provider had a formal process in place for recording of accidents, incidents, and untoward events. When such events occurred, we saw staff reported them appropriately, but follow-up actions were not always completed by seniors.