Greenways

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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

Processes in place as well as the ethos, values, and behaviours of leaders and care staff did not always ensure people using services lead confident, inclusive and empowered lives. Leaders showed a lack of understanding on how to meet the RSRCRC principles. Quality governance systems were not effective in their use. Staff felt confident in being able to speak up if necessary and felt supported in their roles. During our assessment of this key question, we found concerns around the lack of robust oversight and lack of assurance processes which resulted in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Quality frameworks did not always recognise best practice and were not effective in identifying short falls in the care people received or gaps in people’s care records. The deputy manager told us, “We have a brilliant culture, we all live together as a family. Engage in activities. Quite open to any discussions among ourselves.” However, we found leaders of the service did not demonstrate the required experience or capability to deliver person centred care or to ensure risks were well managed. They failed to recognise they had developed a culture that did not robustly promote or uphold people’s rights. We found the Provider and registered manager was not always open and transparent with others involved in people’s care [or during our assessment]. This meant professionals and people’s representatives were not always in receipt of information to make an accurate judgement about the quality and safety of the care provided, which put people at risk.

Policies and procedures were not always fit for purpose. For example, the ‘restraint’ policy did not set out what provider systems were in place to put regulatory or national standards into practice. There was no information about what staff needed to do if they used restrictive practices. It referred to MCA 2005, but failed to explain expectations of the service to carry out an MCA assessment and did not refer to ‘Best Interest’ decisions at all. It did not set out expectations in relation to DoLS and the use of restrictive practice. The training sections of polices we looked at were generic. They did not set out what training was in place in relation to the topic of the policy.

Staff told us they felt supported. One member of staff said, “[Deputy manager] is very supportive and [registered manager] and team leader as well. We do have meetings; I find them useful.” Whilst staff did not raise concerns with us directly, other evidence showed the service had not ensured the workforce were always valued

The provider and registered manager had not considered the impact to staff in working in a high-pressured environment. Throughout the visits, we found staff were always on alert for when people were at a heightened state of anxiety. Staff did not have formal breaks at both of the visits we undertook to the service. We found the Provider and leadership team had not always considered the wellbeing of staff. The registered manager told us staff were not given formal breaks despite working 15-hour shifts. They told us staff got their ‘informal’ breaks when people had their ‘breaks’. However, all people at the service were funded to have a member of staff with them throughout the day and people did not have, breaks as this was their home.

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.

There was a diverse workforce at the service and there were policies in place to ensure staff’s protected characteristics were considered.

We did not receive any direct feedback on this.

The management team told us about the audits they undertook. The deputy manager told us, “I have a monthly manager audit that I do, I do that with medication, check their rooms, safety wise to make sure anything that triggers health and safety concerns. I would ask why it is not done. I do financial audit. I like the fact that you are here. Any concerns we would be able to address." The registered manager told us they worked at the service 3 days a week and these days were also split with another of the providers services. They said the rest of the week they were on call and “My job is to help to support the managers [deputy managers].” They told us, “I will do medication audits, supervision audit, make sure medication, care plan audit. This is all on the system. [Quality manager] has devised a dashboard and does the reports and they use a share point.” However, we found all of the audits we reviewed were either undertaken by the deputy manager or the quality manager.

The provider and registered manager failed to identify through audits that decision specific mental capacity assessments had not been undertaken in relation to decisions that needed to be made. There was also no evidence of Best Interest meetings where restrictions were in place to determine what other least restrictive measures had been considered. The provider and registered manager failed to identify the concerns around staff levels at night, staff not taking breaks and working long hours. They were unable to provide evidence of an effective system to assess, monitor and improve the quality and safety of the services provided and to ensure they had met the requirements of this regulation. The registered manager told us that they did not undertake visits to the service through the night to check on the delivery of care by night staff. They told us they monitored care by reviewing the care notes that needed to be completed by staff each hour. However, when we reviewed the care notes, these were often written retrospectively so you could not be assured that staff were providing the most appropriate care. There were no audits of care notes, care plans, staffing levels and staff interactions with people. This meant they could not be assured that all areas of service delivery were monitored and that actions were taken to improve poor practice.

An external professional told us they had not been involved in reviewing a person’s positive behaviour support plan for at least 2 years.

The registered manager told us professionals were involved in the reviews of people’s care; however, they were unable to provide evidence of this.

The service did not ensure the accuracy of information shared with others involved in people’s care. For example, a person’s relative was aware the door could be locked in response to distress to protect the person and others from harm, however, they were not aware the person was routinely locked in their room and secluded at night. Records showed that in January 2024 the service told the local funding authority that compatibility issues between 2 people were managed well. This contradicted other records which showed their interactions continued to cause a person significant distress.

We did not receive feedback in relation to this.

We found there was not sufficient learning around care being delivered to achieve better outcomes for people. Records in an incident log, dated July 2023, recommended that a person and another person’s time in the house together should be limited to avoid distress. The provider put a risk assessment in place in November 2024, which was untimely, and we found mitigations in the risk assessment were not implemented by the service and there was no review. Incident reports showed the person continued to experience severe distress and harm to themself

The registered manager told us 1 person was being moved to another service in late March 2024. They said this was taking place to improve the person’s life and of those who lived at Greenways. However, we found this had not been planned or coordinated and we have now been informed this move is not taking place.