Clifton Gardens Resource Centre

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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

The provider had failed to effectively implement systems and processes to monitor and improve the quality of care and experience. They had also failed to effectively implement systems to assess, monitor and mitigate risks. As a result, people did not always experience good quality or safe care. We did not assess all the quality statements within this key question. We did not identify concerns relating to these areas which we judged as being met at our last inspection.

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 staff told us the registered manager was approachable, supportive, and provided good leadership. They explained that there had been improvements to the service under their leadership. Their comments included, ''We are listened to and respected by [the registered manager]'' and ''We discuss what has gone wrong and how we can improve as a team.''

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.

The staff told us that problems with the environment and staffing deployment made it difficult for them to provide good quality care.

The systems for identifying and mitigating risk had not always been operated effectively. People were placed at risk because plans to manage these risks were insufficient. Improvements were needed within the environment, as well as regarding how safety was managed and how people's individual needs were assessed and planned for. Failure to effectively implement systems and processes to assess, plan for and mitigate risks was a breach of Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

The staff did not always have the skills, training or knowledge to provide good quality and safe care. This was evident from our discussions and observations of staff. Staff and leaders did not demonstrate a good understanding of how to make improvements when needed.

There were inconsistent processes to ensure that learning happened when things went wrong. The systems for monitoring and improving the quality of care were not implemented effectively. Whilst the registered manager had identified some areas where improvements were needed, these had not always been acted on in a timely manner. The provider had failed to identify and/or rectify poor quality care planning and assessment, lack of person- centred care and risks to people's safety and wellbeing. Failure to effectively implement systems and processes to monitor and improve quality of care and experience was a breach of Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.