Merle Boddy House

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 assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was previously in breach of the legal regulation in relation to good governance. Improvements were not found at this assessment, and the service remained in breach of this regulation.

This service scored 25 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. We identified a lack of transparency and openness in relation to the reporting and escalation of incidents and concerns to external stakeholders including the Local Authority and CQC. This did not protect people from the risk of harm or uphold their human rights and protected characteristics. Some staff demonstrated a lack of understanding in relation to the needs and abilities of people living at the service.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. We identified significant failings in the lack of oversight of the service at a board of trustee level. This did not ensure board members were aware of risk and concern arising from the service, impacting on the safety, quality and standards of care provided. There was also a lack of oversight of leaders and staff performance, and their adherence to policies and procedures by the board.

People did not feel they could speak up and that their voice would be heard. The service was at risk of developing a closed culture, due to information not being reported externally. We identified concerns relating to the performance and judgement of certain staff and leaders in relation to the handling of concerns and incidents and found these had not been dealt with openly and transparently. Following our assessment visits, further concerns arose around staff having escalated concerns to leaders, and this information previously not being acted upon. We have received assurances from the provider that all concerns are being fully investigated as an outcome of this assessment.

The service did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who work for them. A lack of learning and acting on concerns and incidents happening in the service resulted in the absence of ongoing reviews of performance to drive improvements in care and standards of staff performance. Role specific training and development was required to support staff to fully recognise their individual responsibilities, and ensure they had the skills to recognise and support people as individuals. Systems and processes were in place to support equitable staff recruitment processes.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance systems and processes in place were ineffectual and had not identified the areas of risk and concern found during this assessment. Leaders demonstrated a lack of understanding of their regulatory responsibilities in relation to reporting to external stakeholders. We identified gaps in the completion of staff supervision to ensure individual performance and development needs were regularly monitored and addressed, to ensure staff could meet people’s care and support needs effectively. Where incidents had been investigated, the quality and lack of thorough investigation did not drive improvement in individual or service level performance.

The service did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. We identified concerns regarding relationships and communication between the service and commissioning bodies. A lack of effective reporting and escalation to the local authority did not ensure external professionals were fully aware of the level of risk and concern arising within the service, to ensure this information was fully considered when making important decisions regarding the suitability of individual’s placements and funding agreements. This in turn had a negative impact on aspects of people’s lived care experiences.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. Leaders were not supported by the board of trustees to recognise and achieve required levels of service improvement, due to the lack of oversight of the day to day running and safety of the service. We identified examples of missed opportunities for staff learning following accidents and incidents. Leaders had not built networks with other organisations and local initiatives to broaden their knowledge of innovation and good practice happening within the wider care sector.