Whitstable House

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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

We found significant shortfalls in the oversight and management of the service, identifying a breach of regulation. The oversight of the quality of the service was inadequate, the systems and processes in place had not identified any of the concerns we found. There was a closed culture within the service, the management team had not investigated or reported safeguarding incidents. They had not identified patterns, errors or trends within medicines management, complaints or incidents. Staff had not always raised concerns and when they had, the management team not acted on these concerns. People were not given opportunities to speak up about their experience of care and living at the service.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they attended staff meetings and were asked for their opinions. However, these had not always been used to give staff updates and information, share good and poor practice to take the opportunity to coach staff. When incidents had occurred, though staff told us they were confident to raise concerns, they had not been open and reported incidents.

The management team had not encouraged and supported an open and transparent culture within the service. When incidents had occurred, these had not been investigated in an open way. The management team had made assumptions based on what staff said, which meant incidents had gone unreported to the appropriate agencies.

Staff told us they felt the management were supportive. Staff though confirmed they were shortfalls including the oversight of clinical skills, supervision and checking competencies. This had impacted people’s experiences.

There was limited oversight of staff and their ways of working. Staff were required to attend training, but the system in place to check staff competencies was not effective. When incidents had been reported involving staff and their skills such as moving and handling, no action had been taken to assess their competency. Staff had continued to work as before. Following the assessment the provider sent us evidence some staff competencies had been assessed.

Staff told us they were confident to speak up, however, we were not assured they had spoken up when things went wrong. There had been instances where people had reported incidents to the management team and staff had not reported these incidents. Staff had not always recognised when things had gone wrong and action was needed. The management team told us they had investigated incidents but records showed these had not been rigorous and had not been open and transparent in the outcome.

There were processes in place for staff to speak up. However, these had not always been understood and followed by staff. Some staff had not understood what whistle blowing meant and had not spoken up when things went wrong. The management team had not held regular meetings or supervisions to discuss poor practice and training needs.

Staff told us there was a diverse workforce and staff were treated equally.

The provider had policies and procedures in place to support a diverse and equal workplace.

There were processes in place to monitor the quality of the service. Audits and observations had identified shortfalls in areas of the service starting in March 2024, however, these shortfalls continued at the time of our assessment in November 2024. There had been no improvements made in this time. The provider told us, they had put extra resources into the service. An induction manager had started at the service shortly before our assessment, their role was to support staff to complete a second induction, and staff competency.

The systems and processes to assess and monitor the quality and safety of the service had not been effective. During the assessment it was found there were serious shortfalls around individual risk assessments, medicines management, incident and accident reporting, and staff understanding about the application of the Mental Capacity Act 2005.

The management team had failed to make improvements to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users. We found there had been limited identification, assessment or mitigation of individual risks. Staff did not always have guidance in how to manage people’s risks when providing their care.

The oversight of the service through auditing and monitoring systems had not been robust in making sure improvements were made, the same concerns including medicines management had been continually identified since the service opened. The management team confirmed the processes and systems in place did not always monitor the quality of service delivery or care practice, and this could impact how people received their care and support.

People told us they received support from other professionals when required. People told us, their opinions and wishes had not always been considered and staff’s opinion had been taken instead. People felt they had been ignored at times and had not been consulted when decisions had been made about their care and support.

Staff told us they worked with partners such as other health professionals. However, staff had not recognised the need to involve people as much as possible when speaking to and working with health professionals. Due to this the outcome for people had not always been in line with their choices and preferences.

Partners told us they were meeting with the provider as there were serious concerns about the service, which the management team had not identified. External partners were monitoring and working with the service to improve the safety and quality of care. It was noted there had been some improvements however, this improvement was a result of external engagement.

The processes in place had not been effective, the management team had not identified when the service needed to involve other social care professionals to keep people safe, such as reporting safeguarding concerns responding to incidents in a timely manner.

The compliance manager confirmed they had not been fully aware of how serious the shortfalls within the service were and action taken had not been effective.

There was limited evidence the service had learnt and made improvements when things went wrong. The management team had identified improvements were needed, records show shortfalls were found, for example, in medicines management and mental capacity records in March 2024 but these shortfalls continued at the time of this assessment. The compliance manager confirmed they had not been fully aware of how serious the shortfalls within the service were. They were not able to demonstrate how actions taken were effective to ensure people received care that was safe, effective, caring or responsive to people's daily needs.