Northway House

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. This is the first inspection since the service was registered to the provider Pebblestones Limited. This key question has been rated requires improvement: This meant the service 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 regulation in relation to good governance as monitoring and auditing was not effective in identifying shortfalls and driving improvements.

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.

The service had not always had 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. There had been multiple changes to the management team at the home. The current manager had made considerable changes at the home. They told us the main challenge they faced was the culture of the home which they felt did not always promote people’s wellbeing. We noted this had been discussed at staff meetings to ensure everyone was aware of expectations. The manager told us they wanted to create a non-judgemental environment where people could have fun.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The new manager was open and transparent and was committed to making improvements. A care co-ordinator had also been employed who worked alongside senior staff to lead by example and monitor practice. Staff were complimentary about the current leadership. They described the manager as “Firm but fair.” One member of staff told us, “Things are much more organised now. There’s a good handover and allocated tasks.” The new manager was being supported by staff from other services owned by the provider and had an action plan for further improvements.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Managers encouraged people to raise concerns. All staff said they would be comfortable to raise any worries with the manager. One member of staff told us, “Anything – just report to the manager and they would act.”

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff felt fairly treated and respected by the management team and their colleagues. Throughout our visits we saw staff worked together as a team. The provider had policies and procedures to make sure staff were fairly recruited and treated.

The service 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. There was a lack of provider oversight of governance systems. Audits designed to monitor quality were carried out. However, these audits had not been effective in identifying shortfalls. For example, care plan audits had not highlighted any issues. However, we found 4 people had very basic care plans which did not support staff to provide effective, personalised care. Medication audits had not identified issues raised at this inspection. Some checks relating to the safety of the building had not been carried out. Where shortfalls, such as uncompleted cleaning schedules, had been identified, prompt action was not always taken to address this.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. The staff worked with other professionals and groups to meet people’s needs and promote their wellbeing. No one raised any concerns about access to specialist services.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. The manager acknowledged that improvements were needed to make sure people always received high quality care and support. In house and external audits had not led to learning or improvements being made in a timely way. One member of staff told us, “There have been improvements recently but there is more to go. We have started to put in place better routines, and we need to build on things together.”