High Lea 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 good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance/

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The home had recently appointed a new manager who was not registered at the time of our visit. The manager told us she recognised improvements were needed.

We spoke with the provider who explained the home had been up for sale for 2 years and this had impacted on making improvements.

The provider told us they visited the service daily but did not record any formal checks or audits. These visits had failed to identify the concerns we found during the assessment with regards to the environment, risk management, safe care and treatment, staff support, person centred care and good governance.

Following our visit the provider informed us that the manager had commenced registering with the commission and the manager sent us an action plan to address the concerns we had found during the visit.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Staff said the new manager had an open-door policy and was supportive. People knew the manager by name and were complimentary about them, one person said, “I get on very well with [name of manager]. They are always about and checks we are all ok.”

Quality monitoring visits undertaken by the provider were not effective in identifying concerns we found during our inspection. The service had not been well led in the absence of a manager in previous months.

The new manager and provider recognised that improvements needed to be made and after our visit commenced making the required changes.

People did not feel they could speak up and that their voice would be heard.

Staff we spoke to shared concerns about their confidence in speaking up, they told us that a member of staff had recently been dismissed for raising concerns about the quality of the service.

The home had a policy about how to whistle blow on poor practice, however this was out of date and was not available for staff to use as it was kept away from the home.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We could not be assured that staff with protected characteristics would be treated equally as the home did not have a policy outlining how they would ensure staff were treated equally.

Staff were not included in improving the service as they were not given the opportunity to provide feedback through staff meetings, surveys or individual supervisions with management.

After our visit we were sent an action plan for improvements which included re-introducing regular staff meetings, an annual staff survey and regular one to one supervision for staff.

The provider 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.

There was a lack of systems to ensure staff had suitable and sufficient information to follow in relation to risks to people. Care plans and risk assessments for people either contained out of date information or did not contain enough information to help staff support people safely.

Policies and procedures to guide the running of the home were not available for staff to follow as they were not kept on the premises. Policies were limited in their scope and had not been updated. For example, the infection control policy stated that the home was still following guidelines in place for the COVID pandemic.

There were no systems in place to provide governance of the service. Audits were not being carried out and therefore missed opportunities to identify areas where improvements were required. The provider told us they made daily visits to the service and made checks, however, these were not recorded and not effective at identifying the issues we found during the inspection.

After our visit we were sent an action plan which included developing governance systems including reviewing care documentation and policies and procedures.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Families of people using the service were not asked by the service formally for feedback as the last survey had been sent over 2 years ago. Residents’ meetings had not taken place for approximately the same time.

We found that care records in place were not always up to date, accurate or sufficiently detailed. Therefore, when information about people needed to be shared between services there was no assurance of the quality of information shared.

Professionals that work with the service provided positive feedback about the service.

The provider 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.

The leadership team were not proactive in obtaining information through audits, incidents, and safeguarding alerts to improve the service. They were not working with staff to understand how things went wrong and involve them in finding solutions. The provider had not ensured that incidents were investigated, and lessons learned complete.

Action was required to ensure good leadership and effective systems were in place to drive learning and improvement at the home.