Archived: Asquith Hall

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 this key question was rated requires improvement. At this assessment, the rating has now changed to inadequate. Governance systems were ineffective in identifying and monitoring shortfalls and making improvements. The culture in the service was not inclusive, fair, open and transparent and there was a lack of learning taking place to improve people’s experiences. There was a culture of accepted neglect whereby leaders and staff did not challenge or improve inadequate standards of care and people living at the service had to accept substandard care as normal. Leaders did not have the knowledge and skills to lead the service effectively and information relating to risk was not acted upon. Staff did not feel confident in speaking up and people at the service did not have a voice. The provider did not effectively work in partnership with other services. We identified 5 breaches of regulation in relation to person-centred care, safe care and treatment, premises and equipment, staffing and good governance.

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.

Leaders and staff did not demonstrate a shared vision, strategy or inclusive culture at the service. People were not being cared for and we observed numerous people being significantly neglected and placed at risk. For example, a person who was living in squalid conditions and not being supported with personal care. Such significant instances of lack of care had not been challenged by leaders or staff and nothing had been done to help the people affected. There was no consideration given to equality and people’s human rights. There was a lack of transparency and inclusion, indicative of a closed culture. People’s needs were not understood or met.

Systems and processes had failed to support a positive, inclusive and open culture where people’s needs and rights were respected by leaders and staff.

There was a lack of consistent, safe and effective leadership and management, which impacted upon the quality and safety of the service. Leaders did not have the skills and knowledge to lead effectively. During many discussions with them throughout the assessment process it was clear they did not know people well and they failed to take action to meet people’s needs. When inspectors shared serious concerns with leaders regarding people’s safety, they lacked compassion towards the people involved. They did not model an inclusive, open and positive culture. We found there was a lack of effective communication between the management team and staff. Staff handover information was not adequate for staff to understand the risks to people and be able to provide safe care and treatment.

There was no registered manager in place. There was a covering manager and several senior leaders deployed by the provider to support the service. However, collectively they did not demonstrate effective leadership, oversight and knowledge of people and failed to ensure person-centred, safe and effective care delivery.

Staff were not always confident in speaking up and raising concerns. When staff did raise concerns, they did not feel these were taken seriously. For example, 1 staff member told us, “The managers are very dismissive. They don’t take action. They don’t care.” A second staff member informed us they have raised several safeguarding concerns for a person but did not know whether any action had been taken by the manager as a result of this.

Systems and processes failed to ensure people had the freedom to speak up. The provider failed to take appropriate action when staff did raise concerns.

The culture at the service was not inclusive. Staff were not adequately supported and listened to. Staff did not feel their well-being was considered. For example, 1 staff member told us, “We come second."

Systems and processes failed to support an inclusive and fair culture at the service. They failed to ensure adequate staff support was in place and that equality, diversity and inclusion was considered.

Leaders did not demonstrate adequate oversight. We identified significant concerns regarding the lack of clinical and management oversight and the provision of care. We found risks to people were not identified or met and they were not receiving the care and support they required placing them at risk of harm and injury. This was raised with the provider on numerous occasions however leaders continued to fail to take adequate action to address the shortfalls throughout the assessment process.

Quality assurance systems and processes were not effective in identifying shortfalls and driving improvements. Where shortfalls had been identified, no action had been taken. Systems in place had failed to identify and address continuous, systematic and widespread failings identified during the assessment. Inadequate care provision was evident throughout the service, and we identified regulatory breaches relating to medicines, infection prevention and control, the premises, person-centred care, staffing, good governance, and assessing, monitoring and mitigating risks to people. In addition, the provider failed to maintain securely, accurate, complete and contemporaneous records for each person. This impacted the quality of care and safety of people. For example, care records contained inaccurate and incomplete information relating to people’s care and support needs. In addition, we observed an office left with the door propped open, containing confidential information. The issues relating to records found at the inspection had not been identified or resolved through quality, monitoring and improvement systems and processes.

The service did not work effectively in partnership with other agencies and stakeholders, to ensure people had continuity of care.

Leaders did not demonstrate their duty regarding partnership working to ensure good outcomes for people. Information shared with other agencies was limited. Where feedback was given during the assessment process this was not adequately acted upon to make improvements.

The local authority had been frequently present in the service. There were concerns regarding the responsiveness of the provider where issues had been raised.

Systems and processes failed to ensure effective partnership working leading to poor outcomes for people and failure to improve the service.

The leaders lacked knowledge and skills, to deliver equality of experience and a good quality of life for people. There was very limited evidence of the service having learned from accidents and incidents, or measures put in place to identify opportunities for learning. Leaders lacked the skills, knowledge and experience to identify opportunities for improvement even when feedback was provided to them by key stakeholders.

Systems and processes failed to ensure continuous learning, innovation and improvement across the organisation and the local system.