Salthouse Road

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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 overall rating of this key question is good. The provider responded proactively to a whistleblowing concern, identifying a closed culture in the service and took steps to address this. Staff told us morale was improving and they had confidence in the new management team. However, we found 2 breaches of legal regulations. The provider’s systems had not been effective in identifying issues and driving improvements at the service. CQC had not been notified of all relevant incidents. Required documentation was not always in place and historic issues around staff practice had not been picked up through the provider’s checks and audits.

This service scored 71 (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.

Staff were aware of the whistleblowing procedure and knew how to report concerns through their internal systems. Staff felt confident in their management team and that issues would be addressed. Staff attended team meetings which provided an opportunity to share any updates and openly address any issues. Staff and leaders were open and transparent with us during the assessment.

A closed culture had developed at the service and the provider’s systems of checks had failed to identify this. Once the provider became aware of the concerns, they undertook an immediate review and found issues with some staff practice. They then took immediate action to address the most pressing matters which included disciplinary action. Shortly before our assessment, the provider had implemented a new governance framework to provide assurances. This had included a new management team to drive improvements and additional monitoring and checks. They were also in the process of reviewing what had gone wrong and how they could learn from this. We had concerns that previous staff conduct issues had not been properly shared with a prospective employer. This meant staff could have continued to work with vulnerable people, despite concerns about their practice. We raised this with the nominated individual who took immediate action to address this.

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 system of checks and audits had not been effective in identifying and addressing all points raised during this assessment. This included how elements of risk were managed by staff, some of the environmental issues, lack of supervisions and records which weren’t in place. Checks completed by the provider were not robust and failed to demonstrate sufficient oversight. The last detailed provider audit of the service was undertaken in 2021, with a further check in August 2023. The provider had shared information with partner agencies, including the local authority safeguarding team. The provider had an improvement plan in place, which demonstrated how they were intending to address and resolve issues. However, further time was needed to demonstrate the improvements and how these would be sustained. A new manager was in post and were intending to apply to become the registered manager of the service with CQC. The manager was also actively supported by an experienced manager from another service. The new manager said they had an open-door policy with staff and told us, “We want to get it right, we want it to work so it’s safe and fair for everybody.”

Staff told us morale had been low but this was improving and the atmosphere had lifted. Staff said they felt listened to by the new manager. A staff member told us the manager praised and motivated the staff team. Another staff member commented, “I feel the new management team are amazing; supporting staff, service users and families.”

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.