74 Old Ford End

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to governance. The provider had not always ensured their systems were effective and ensured correct levels of staffing, safe medicines administration and effective care planning that met people’s needs and preferences.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a clear shared vision, strategy and culture based on equity and engagement. People did not always receive care in line with the current best practice guidance of right support, right care, and right culture. For example, people did not always experience good access to local communities, which most people take for granted. This increased the risk that the culture in the service did not always promote people enjoying a full life and having all their needs and preferences met.

The service did not demonstrate they had capable and compassionate leadership. During this assessment, we identified breaches of the legal regulations. This meant leaders had not always identified and taken action to ensure people received care that was in line with legal requirements. However, staff confirmed leaders had an open-door policy and felt any concerns and ideas they had would be listened and responded to. A staff member told us, “[Registered Manager] is absolutely amazing and supportive.” Another staff member told us the registered manager had been supportive in changes to their work pattern to support their wellbeing.

Due to our findings that accidents and incidents were not always reported by staff or identified by the provider, we could not be assured people and their relatives would be informed of these promptly and would be given an apology where required. However, people and relatives did not raise any concerns to indicate they could not speak up or their voices would not be heard. There were systems in place which encouraged the freedom to speak up. For example, staff were able to raise concerns anonymously.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff we spoke with confirmed they were treated fairly. The providers policies promoted equality, diversity and inclusion.

The service did not have good governance systems in place. They did not act on the best information available to them about risk, performance and outcomes. We identified concerns related to medicines, staffing levels, infection prevention and control, safety, care planning and people accessing regular community-based activities. The provider had not independently identified this. However, the provider responded to our concerns which included reviewing these areas, making improvement and planned further actions they would take. We will check for sustained improvement at our next assessment.

People were not always supported in being part of their local communities. Improvements were needed in systems to deliver care collaboratively based on people's day-to-day experiences. However, relatives felt they were kept informed and up to date. A relative said, "I feel involved with [Person's] care plan, and they ask me for advice.

The service did not demonstrate they had learnt and improved from our previous inspection. We identified similar shortfalls related to person-centred care and good governance during this assessment. This meant we could not be assured leaders had a good understanding of how to make and sustain improvements at this service. This placed people at continued risk of not receiving care that met their needs and preferences.