Ordinary Life Project Association - 5 St Margaret's Gardens

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

We looked at 4 quality statements under the key question well led. We found the service was in breach of Regulation 17 1,2(b) (c) and Regulation 18, 2(a) of the Health and Social Care Act (Regulated Activities) Regulations 2014.

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.

Induction records reflected corporate strategies were not routinely shared with staff when they started their employment. This meant the provider could not be assured they were delivering services in line with their own strategy.

Staff could not identify corporate strategy or goals meaning they could not identify outcomes for the service. When the inspector asked the registered manager what the corporate strategy was they could not identify one. This meant the provider could not be assured they were delivering services in line with Right Support, Right Care Right Culture

The registered manager showed us records that demonstrated staff were being supervised regularly and that the registered manager was holding team meetings, however these were not always effective in identifying issues with training for staff or that key workers were not keeping service user files up to date and relevant.

The registered manager was predominantly working in the service which left little time to complete management tasks needed to lead within the service. The registered manager had identified this as an issue but had not been able to find a resolution. This meant they did not have the time to ensure all management responsibilities were being completed. Staff told us they felt supported by the registered manager, however they did not see other more senior managers on a regular basis. The registered manager ensured staff had supervisions and staff meetings regularly. However these had not always identified issues for staff such as lack of training.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Two members of staff told us there was an incident within the home involving service users and a member of staff. Whilst the provider did ensure that there was an increase in staff to support the staff member in the short term, the provider did not meet them to debrief after the incident for over a week. The provider expected a new member of staff who had not completed their mandatory training to lone work after the incident without ensuring the staff member felt this was safe for them and the service users. The staff member told us that they were very anxious about doing this. Whilst some people had up to date care plans other people’s plans did not reflect their current support needs, this meant that the manager could not be assured people were being supported safely. One person was not receiving the 1 to 1 support that had been commissioned for them this meant that they were not able to access activities they enjoyed. There was a file for agency to refer to for guidance on supporting people however the information within it was not current or complete. This meant the manager could not be assured that people were being supported safely and in line with their current needs.

The provider did not always ensure that systems and processes to support people and staff were in place. Staff told us they did not feel the provider had processes in place to enable them to support people safely. Inspectors requested guidelines from the provider relating to supporting service users involved in incidents but none was provided. This meant that people were at risk of not having the appropriate support. Care plan records of service users that were reviewed as part of this assessment indicated information about how to support people was not easy to access nor was it always up to date. Risk assessment which were reviewed as part of this assessment did not always represent service users current risks. The registered manager did not have a process in place to complete competency assessments for agency staff who were lone working in the service.

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.

One member of staff had been employed for 6 months but had only completed 2 training modules. A further member of staff who had recently been recruited was lone working before they had attended any training delivered by the provider. This meant the provider could not be assured staff were working safely . Some staff told us that they did not always feel safe when lone working as they had not received the relevant person specific training to support them to work with the service users. Other staff told us they were up to date on mandatory training. Staff told us at their latest team meeting they had the opportunity to suggest different activities for people to do during the summer.

The registered manager had not assured themselves through their process of auditing and supervision that all staff had attended the training courses they needed to ensure they were working effectively. The provider could not demonstrate they sought to be innovative in their development of the service. The registered manager had liaised with other professionals to support 1 person who was new to the service. They had also liaised with specialist services for 1 person who had changing support needs and were introducing different ways of working for this person.