180 Surrey Street

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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

The provider had not established and operated effective systems and procedures to assess and monitor the safety and quality of the service. During our assessment of this key question, we found concerns around provider audits, oversight and leadership of the service which resulted in a breach of Regulation 17 Good governance 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. The registered manager had oversight of the needs of individual people and staff. They were suitably qualified and experienced. There were opportunities for staff to share their views about the quality of the service. The provider and registered manager were working with local authority commissioners to implement improvements to meet their commissioned contractual requirements.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff we spoke with understood their roles and responsibilities. These were discussed at one to one meetings to ensure best practice. Staff told us they liked the registered manager, felt they were approachable and felt supported although some staff reported minor concerns had to be raised several times before the registered manager took action. The registered manager had oversight of the needs of individual people and staff. They were suitably qualified and experienced. They told us they were working with local authority commissioners to help monitor and improve the quality of the service.

The provider had relied on intervention from local authority commissioners before making required improvements. They had developed an action plan and were in the process of implementing changes around governance and leadership to ensure a more proactive approach to identifying and sustaining improvements.

There were opportunities for staff to share their views about the quality of the service provided. Staff confirmed they had the opportunity to attend meetings but could talk with the registered manager at any time. A staff member told us, “We are encouraged to raise concerns and we can do this easily with the registered manager. We are also made aware of the whistle blowing policy and procedure and encouraged to use this if we feel we need to.” The registered manager told us they encouraged staff to raise concerns or make suggestions in staff meetings and informally. The registered manager saw concerns and complaints as an opportunity to ensure lessons were learnt and improvements made.

The registered manager sought people's views on a regular basis, formally and informally, to ensure they had an overview of how people felt about the care and support provided. Care reviews ensured people’s voice and feedback was at the centre of the care provided. The provider encouraged an open and transparent culture with seeking feedback by people and their relatives. The leadership team promoted the principle of freedom to speak up and investigated thoroughly before acting promptly on received complaints.

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.

Staff provided mixed feedback about the governance, leadership and oversight. Care staff told us the management team supported them and they, as a team, supported each other and management, but sometimes responses were slow to changes or concerns. The registered manager explained the various methods used to maintain oversight of the service. Following intervention from local authority commissioners, these systems were still being embedded at the time of our assessment. The registered manager told us there were clear lines of communication and all staff understood their specific areas of responsibility. Feedback from staff confirmed they understood their responsibilities and how to communicate concerns. Staff told us they received spot checks on their work and performance. One staff member told us, "[Registered manager] is supportive but also very strict about how we should work as professionals. They make sure we are helping people in the right way."

We found governance systems remained fragmented and the provider was not proactive in identifying and making required improvements without intervention of external agencies. Audits had been implemented but these did not clearly evidence impact of actions taken in response to service failings. Systems and processes were not always used effectively to identify improvements at an early stage and ensure remedial action was sustained. For example, audits and checks had not identified some risks assessments were not sufficiently robust or detailed. Audits identified some visits were ‘mostly within commissioned hours’ but failed to identify staff were leaving some calls early with no supporting evidence to validate this. The provider had not established and operated effective systems and procedures to assess and monitor the safety and quality of the service. This was a continued breach of Regulation 17.

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.

The provider and registered manager were working with local authority commissioners to implement improvements to meet their commissioned contractual requirements. They told us they had taken the opportunity to reflect on leadership and governance and had made changes around management structures and roles to improve the oversight and governance of the service. They were in the process of making additional changes they felt would make further improvements and ensure these were sustained. These improvements were not embedded at the time of our assessment. The registered manager was able to provide examples where staff had worked with individual people to help them achieve better outcomes from their care, including a reduction in level of distress and improvements in communication.

The provider had begun to make improvements across the service with input and support from local authority commissioners. For example, they had recognised they had not used electronic call monitoring effectively and had retrained staff and were in the process of improving the implementation of this at the time of our assessment visit. The provider had also recognised daily management oversight of the service had not been effective and had introduced new management roles to improve monitoring and assessment of the service provision. These improvements were at an early stage and it was not possible to assess the impact of these at the time of our assessment.