Archived: Walsingham Support - 21 Budge Lane

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

At the time of our assessment, the provider did not have a stable management team in post. Management cover was arranged while the provider was recruiting for the permanent manager’s position. The acting manager and management team were open and honest about the difficulties of managing the service in circumstances where the previous manager had left at short notice and a handover had not been possible.

Family members of people using the service did not feel listened to and described their communication with the service as not effective.

Staff were confident to raise the concerns they had. The provider fostered a culture in which staff were encouraged to speak up.

The provider promoted a shared vision and culture for the service. The provider valued diversity and took steps to create an inclusive culture for its employees.

The provider was not implementing systems to ensure good governance of the service. There was no evidence of monitoring of the safety and quality of the service and therefore no evidence that actions were being taken to improve care delivery.

The provider did not work consistently with partners to ensure services were working well for people.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team told us that recently a new set of organisational values had been put in place, aiming to bring all the provider services to work together. Learning and development was facilitated in management and team meetings focusing on embedding the new values into the services' everyday practice.

The provider promoted a shared vision and culture for the service. The organisation’s values were outlined to staff on an ongoing basis and shared with staff in a “values and strategy” document. The provider promoted open and transparent discussions during team meetings and staff concerns were recorded and addressed.

At the time of our assessment, the provider did not have a stable management team in post. Management cover was arranged while the provider was recruiting for the permanent manager’s position. Staff told us that management guidance and support was available to them when needed, commenting, “The new manager is good, if you need advice, you can tell her or write in the [communication] book, and she will sort it out for you.” However, on the day of our visit we found that the staff team were not able to promptly get hold of the managers to let them know about the assessment taking place. Although the permanent staff member appeared confident in their role to oversee the care delivery, we also saw them carrying out tasks that they were not skilled to undertake, such as inducting a staff member on their first day in the new role.

The provider did not have capable leaders at the service with the knowledge and experience to lead effectively. The previous manager had left the service without there being another manager recruited to the position. Although there were temporary management arrangements in place whilst the provider was in the process of recruiting for the vacant manager’s position, the acting manager was unable to answer questions about the running of the service. They could not provide all information requested as part of the assessment process and did not always respond to requests for further information. The acting manager and management team were open and honest about the difficulties of managing the service in circumstances where the previous manager had left at short notice and it had not been possible to arrange a handover.

Staff were confident to raise the concerns they had. Staff knew the actions they had to take, including reporting to the management team and partnership organisations if information of concern was made available to them. They said, “I would escalate [concerns] to someone within the organisation and after the CQC and the safeguarding organisation if necessary” and “I have to go [with concerns] to the assistance manager or shift leader or write in the [communication] book.”

The provider fostered a culture in which staff were encouraged to speak up. There was a whistleblowing policy and procedure in place, which outlined the process to be followed where staff raised concerns. Although we found there were no whistleblowing records, we saw staff meeting minutes showed staff were being open about their concerns about the service and the management response to these concerns was also recorded.

The provider was in the process reviewing their systems in place to support staff’s wellbeing.

The provider valued diversity and took steps to create an inclusive culture for its employees. We saw there were policies and procedures in place to support staff with different needs. For example, there was a menopause policy, an expectant mother policy and an equality and diversity policy in place. These policies supported leaders in managing people’s needs to ensure equity of opportunity in the workplace.

Changes had recently been made to the management structure in order to improve oversight within the home. The provider had decided to have a full-time manager in post to oversee the care being provided for people. The service manager told us they aimed to recruit an experienced manager making sure they were able to provide the necessary support for the service.

We saw the last CQC inspection ratings being displayed at the service as required by regulations.

The provider was not implementing systems to ensure good governance of the service. Since the departure of the previous manager, an acting manager had been put into post, but they did not have the necessary knowledge and oversight of the service to deliver good quality care. Although the acting manager was aware of some of the areas in which the service needed to improve, they could not demonstrate any audits were being taken in any aspect of the service. There was therefore no evidence of monitoring of the safety and quality of the service and therefore no evidence that actions were being taken to improve care delivery.

This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Family members of people using the service felt not listened to and described their communication with the service as not effective. Their comments included, “Communication is a big concern; to say it’s poor is an understatement. I relied on one key care worker for communication, not management”, “At the moment I’m not aware of anything that’s going on, no one at Budge Lane have communicated or rang me”, “I ask but no one sends or informs you of anything. I said they could update by email, but I’ve not had anything”, “In 2 years I had seen 4 managers there” and “It’s gone down a lot from a few years ago.” Some family members also told us they were not invited to attend the service’s review meetings to discuss the care being provided for their relatives.

The provider worked in partnership with external organisations to support people's wellbeing. The management team told us they liaised with the health and social care professionals as required to support people’s care needs. This included regular meetings with the Local Authority in relation to safeguarding concerns being raised and the GP who knew people very well and visited the home when needed.

The provider did not work consistently with partners to ensure services were working well for people. At the time of our assessment concerns had been raised by the local authority that the provider was not fully sharing information about people’s care. This led to increased local authority oversight, which the provider was responsive to.

Processes were in place for the provider to work with partners to ensure services were working well for people. Regular meeting were held with professionals and the local authority for the oversight of care delivery.

Staff told us their suggestions about how the service can be improved were taken into consideration by the management team. One staff member told us, “In general if we put all the managers together, they listen.” An action plan was in place for making the necessary changes at the service to improve the care being provided for people.

The service manager told us they were in the process of reviewing people’s care plans and recruiting staff to ensure safe and effective care delivery at the service. They also said, "It takes a while to make changes. First thing is we are making sure people are safe and staff are supported. There is a lot to do."

The provider was unable to demonstrate they had the necessary systems in place to improve the service. The provider had details of all complaints and safeguarding concerns that had been raised at the service on their internal system. However, they were unable to provide evidence of investigations that had taken place as a result of these concerns. They were therefore unable to evidence that improvements were being made when things went wrong.