Grove Park

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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

We assessed seven quality statements within the well-led key question. There was a lack of effective clinical oversight and governance to ensure people received care and treatment that met their assessed needs. There were widespread and significant shortfalls in peoples care which had not always been identified and when this had occurred there was insufficient action taken to ensure service users received timely and appropriate support to meet their needs. Incident and accident reports were not completed or monitored to identify trends to improve the safety and quality of the service. Oversight systems and processes had failed to identify shortfalls in staff practice or consider risk mitigation measures. This was a breach of Regulation 17 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Good governance.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some staff, the registered manager and the provider spoke of closed culture concerns. The registered manager told us, "It’s the culture of seeing it and doing nothing is a worry for me.” There was a proportion of the team did not feel included and empowered to speak openly in the workplace. This resulted in shortfalls in transparency and staff not reporting concerns. This meant injuries to people had not always been fully investigated, risks mitigated, or lessons learnt. We sought assurance from the provider as to actions they were taking, they told us, “The review is showing themes of non-support from management or visibility, management not listening to concerns or acting on them.”

The provider did not have effective systems that assessed or monitored the day to day culture of the service, and this meant they had not identified the warning signs of a closed culture noted during the inspection.

Staff provided mixed feedback about the openness of senior leaders. One spoke of the registered manager, “They always have an open-door policy, anything we need to talk about they are always there.” Others felt they were unable to share their concerns. Following our assessment visits the provider has demonstrated openness and honesty about actions they were taking to address significant shortfalls which included all staff receiving support from leaders.

The providers processes had not effectively measured the skills and competence of senior leaders and as a result had failed to ensure they received support to lead effectively. Subsequent to our assessment visits the provider identified incidents which had not been managed in accordance with safeguarding policies and processes and took action to report these to the local authority and notify CQC.

The provider, registered manager and some staff have shared concerns regarding how staff had not felt safe to speak up. This meant there were significant concerns with how this impacted the quality of the service people received. We sought assurance on actions the provider was taking to address these concerns. They told us, they planned to complete a closed culture review.

Systems designed to gather feedback from people and staff had failed to identify significant concerns about the culture of the service where staff have not felt able to be open when things went wrong.

Most staff told us they enjoyed working at Grove Park. Some staff said they felt confident that any issues raised would be listened to and considered, this was contrary to the experiences of others. The provider had met with staff to ensure they were clear about their rights as employees, they told us, “I have spoken to all staff to ensure they understand they have nothing to fear.”

Processes in place had not effectively monitored the experiences of some staff. Policies, procedures and quality assurance processes had not sought to consider specific cultural challenges or identified the significant shortfalls in the experience some staff received.

Staff did not have a clear understanding of their roles and responsibilities with incident and safeguarding reporting or medicine processes. Staff consistently told us they took photographs of injuries affecting people. Some staff were not able to explain what the next steps would be or how they acted to mitigate risk. Senior staff and managers failed to monitor staff practice which then resulted in a failure to investigate incidents resulting in some people being subject to potentially avoidable harm. The registered manager told us they expected trained staff to ensure incidents were reported, “As a nurse they are clinically responsible on the floor. As registered manager I would expect these to be raised.” The registered manager spoke of how they had raised concerns with shortfalls in incident reporting and themes in handover and “Harm Free meetings”. They were unable to provide assurances they had monitored staff performance or reduced the potential risk to people.

Oversight systems and processes were either not in place or had failed to identify shortfalls in staff practice or consider risk mitigation measures. Medicine audits were not available or contain adequate information to effectively identify concerns, monitor stock of medicines (including schedule 2 medicines) or identify concerns with PRN. There were no clear protocols to advise staff when they should offer and administer service users their medicines that were prescribed on a PRN basis and this increased the risk that service users would not receive their medicines in accordance with prescribers’ guidelines. There was little or no evidence of learning from incidents, reflective practice or service improvement as a result people continued to be at risk of harm.

People told us staff and leaders collaborated with health professionals and supported them with appointments. Relatives provided positive feedback, one told us, “[Staff] always happy to help they follow up on health appointments quickly, antibiotics for example sometimes started on the same day.” However, people were not always supported appropriately. People's care and treatment was not always managed effectively. We found evidence that people were waiting longer than needed for referrals to be sent to other healthcare professionals. This was largely because of ineffective communication between staff and lack of leadership.

Staff told us people received regular input from community health professionals who visited Grove Park regularly. Senior staff and the registered manager spoke of challenges they had when sharing information. For example, Grove Park were operating two different sets of medicine documentation one online and the other in paper form.

Health professionals who have regular contact with Grove Park expressed concerns with communication which impacted on their ability to collaborate and work together to provide quality support to people. One professional told us, “Communication is an area that could be improved. It is often difficult to get through to the team on the phone…It can then be difficult to identify if tasks have been completed for residents.” Another told us, “I have observed some staff have limited English / confidence when discussing residents and query how much positive interaction they can be having with residents with a progressive dementia and existing communication difficulties.”

Systems in operation had failed to pick up on feedback from visiting professionals or ensure the service was always working collaboratively. For example, we have commented on shortfalls in staff dementia knowledge and health professionals reported they had offered additional support. Leaders had failed to prioritise potential opportunities for learning designed to improve the quality of support people received.

Staff spoke of training they had completed including dementia and how they supported people when they appeared confused or distressed. Staff had completed records relating to care which evidenced shortfalls in their knowledge of good practice guidance about supporting people with complex needs. This increased the risk of people not receiving safe, effective care. Records showed that staff had safeguarding training, however there were significant shortfalls with staff knowledge. The provider told us investigations after our assessment visit meant that a responsible person was referred to professional bodies and safeguarding. Leaders told us, "We were unable to locate the safeguarding tracker for the nursing unit. This meant we had no idea of what incidents were currently being dealt with and as a result, learning couldn't take place as quickly as we would have liked." Leaders told us that a new tracker is now in place.

The provider did not have quality monitoring systems in place to monitor staff practice that would have identified the need to ensure staff practice was in line with their training. The provider had failed to ensure staff had effective training to support people with complex needs including dementia and behaviours that challenged. People were highly dependent on staff knowledge and skills. Processes designed to be opportunities for staff to learn and be heard were not always effective. For example, a staff meeting had noted staff to read the whistle blowing policy, however, the notes suggest the tone of the meeting was primarily to remind staff of shortfalls and concerns with their practice. This did not promote an open and inclusive culture within Grove Park. The providers oversight processes had not identified or addressed concerns. This meant staff continued to not speak up and resulted in people continuing to be at risk of harm.