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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

There had been a number of manager changes since opening in June 2023. This had led to a lack of consistent, robust management oversight. During the period of our assessment, the provider had brought in a registered manager from another of its services and work was undertaken to respond to the safeguarding concerns promptly and work through a programme of improvements. We identified numerous other shortfalls at the start of our assessment. However, the provider was responsive to our concerns following feedback. A permanent new registered manager was employed, and improvements continued to be made. These now need time to embed.

This service scored 25 (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.

Work was in progress to engage staff and increase morale, but staff feedback identified there was still work to do to build the team. Several staff commented on the division between original staff and newer staff. We received mixed feedback from staff about the management team. Some staff told us they felt supported by managers, but other staff did not. Several staff told us one member of the management team did not engage with them and they didn’t feel able to go to them for support. Staff had felt unsettled by the number of different managers there had been, which had led to constantly changing expectations of them as staff. At our site visit in June 2024, we found the nominated individual had acted on feedback and there had been a review of, and changes made to the management team and a new registered manager was in post.

Regular staff team meetings took place and staff had opportunities to raise issues and share ideas. These meetings covered a range of topics and updates for staff and allowed managers the opportunity to gauge the satisfaction and engagement of staff. Staff were also encouraged to complete weekly surveys about their work and feedback achievements within the staff team. Processes needed time to embed to ensure all staff understood them and felt able to engage.

Feedback from staff about being able to speak up and raise concerns was mixed. Several staff told us they felt they were able to speak up and would be listened to. For example, “I do feel if I had a concern I could take it to them [management]. They are approachable.” Some staff also commented they thought the nominated individual and interim manager were approachable and could speak with them.” However, other staff did not feel able to speak up, or would only speak to their senior in charge, and not any of the management team. One staff member said when they did raise concerns, they did not always feel listened to and weren’t sure if issues were addressed. Staff told us they knew which external agencies to contact if they needed to raise a concern outside of the home, including the local authority and the police. The nominated individual told us they were working hard to try to improve staff morale as they acknowledged the high turnover of managers. At our site visit in June 2024, the nominated individual told us they had considered staff feedback and made changes to the management team. Staff were much more positive about the new management team who were approachable and supportive. This now needs time to embed in practice.

There were processes in place for staff to speak up and raise concerns. The provider had a whistleblowing policy which staff were aware of and knew where to find. Team meeting minutes from December 2023 and February 2024 showed staff were encouraged to speak up if they needed to raise anything so they could help to resolve it, whilst acknowledging there had been lots of changes. Staff surveys were in place and staff were encouraged to complete them. This was highlighted in a recent action plan to support employee engagement following the results of a recent survey. This now needs time to embed in practice.

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.

During our site visits in March 2024, several staff told us communication was poor. For example, one staff member said, “It’s a bit up and down. Some days you get the information you need, but when I’ve had a few days off I will come back and not be told information regarding things that have happened or changes on my days off.” Another staff member said, “Communication is not great.” A third staff member told us, “It’s the team leaders who are having the handovers. The carers don’t get one.” Some of the management team were aware of the difficulties for the staff. At our visit in June 2024, we found improvements had been made with handovers, team working and allocations of work and staff felt more positive. This will need time to embed into practice. The provider confirmed they had not always reported incidents and events to the commission and local authority as required.

During our site visits in March 2024, we found there had been a lack of robust oversight during a period of multiple manager changes, which had led to shortfalls in governance. Although the provider had robust policies and procedures, these were not consistently followed. Systems to monitor the quality and safety of the service were not always effective. For example, the accidents and incidents audit did not identify when follow up actions had not been completed. This meant the management team could not be assured all incidents and accidents had been appropriately managed, or learning had taken place. The provider was responsive to the issues we raised and had started to take action based on the feedback given. At our site visit in June 2024 new systems were being put in place to improve governance. This will now need time to embed into practice.

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.