8 Acres

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

Breaches of the regulations in relation good governance and oversight of the service were identified, impacting on the standards of care and support people received.

Overall, the provider did not have sufficient levels of oversight of how the service and staff team were performing on a day-to-day basis. This did not ensure people received consistent standards of care and support.

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.

Closed cultures at a provider and management level of the service were identified. As such, we found there to be an unhealthy culture within the service and wider organisation impacting on their willingness to share information with external stakeholders including CQC, local authority safeguarding and the police where serious incidents and accidents had happened involving people living at the service.

The service lacked strong leadership, and the management arrangements in place did not ensure the registered manager had sufficient oversight of the day to day running of the service.

Most staff told us they felt able to contribute ideas to the overall running of the service.

Provider and service level audits were of poor quality to drive quality and improvement within the service. Associated improvement plans lacked oversight to ensure deadlines were met, and individual members of the leadership team were held accountable as appropriate. This did not ensure improvements and ongoing development of the service.

Closed cultures identified at a provider level impacted on the level of compassion shown throughout the organisation. People and staff were not treated with the required levels of care to ensure they felt valued and respected by colleagues and leaders.

We were concerned by the lack of empathy and compassion shown by the provider and leaders when we raised concerns in response to inspection findings. This did not demonstrate an understanding of individual personal and professional accountability, but also did not show a recognition of the specialist service people and their relatives expected to be provided.

The management structure in place at the service left the registered manager removed from the day to day running of the service. This impacted on their levels of oversight and awareness of what people’s lived experiences were like.

Quality audits completed at a provider and service level were not identifying the level of risks and concerns found during this inspection. This did not demonstrate those staff completing the audits were being thorough, or that where issues were identified these were being acted upon in a timely manner to ensure the best quality of life and outcomes for people living at the service.

From reviewing accidents and incident records we identified a number of serious incidents which happened at the service, resulting in staff being injured. When we asked the provider for confirmation of onward reporting of staff being assaulted to the police, they informed us this was not the process being followed to protect staff.

From reviewing governance documents, we identified examples of where staff had raised concerns to leaders, and these had been poorly investigated. This did not assure us that where staff chose to speak up that their views and anonymity were treated with the required levels of respect.

Factors impacting on staff feeling safe and comfortable to speak up without fear of reprisals had not been considered by the provider.

The culture within the provider and management teams within the service and wider organisation did not support staff to speak up internally or externally and feel able to comfortably raise concerns regarding standards of care and support provided by their colleagues.

People and staff individual characteristics were not assessed fully to protect them and ensure any additional support, or specialist training was identified and implemented.

Risk management plans were not in place to protect staff including those staff with known medical risks, from the risk of harm, for example in the management of blood born viruses, and ensuring staff had required inoculations to maintain their safety.

From speaking with staff, we identified that some had low expectations around what they were entitled to receive in relation to training, and how they should be treated and valued as an employee.

Recognised government guidance and procedures were not reflected in the provider’s own policies to protect their staff team. We identified gaps in training and competency checks required to ensure staff fully understand their roles and responsibilities as well as maintaining their safety.

Feedback from the provider and leaders identified poor oversight of the governance systems and outcomes in place at the service. This in turn resulted in poor care outcomes for people and their relatives.

The management arrangements in place at the service did not offer sustainability, as the registered manager was removed from required levels of oversight such as onward reporting to CQC and local authority. From discussions with the registered manager and provider team, we were not assured they recognised their individual regulatory accountability, and the need for an open and transparent approach to reporting and escalation processes within the service and wider organisation.

Governance audits had not identified serious shortfalls and failure within the service found during this inspection. Overall, the service had not been able to sustain or improve their compliance levels since the last inspection, resulting in breaches of the regulations being identified.

Robust risk management and continuity plans had not been implemented ahead of the service moving from paper to electronic care records.

We identified a lack of processes in place for leaders and the provider to oversee the quality of documentation, completed by staff within any 24-hour period of care intervention. Without these processes in place, risks around poor recording, and significant gaps in overnight welfare checks being evidenced as completed had not been identified to protect people living at the service.

Improvements to people’s involvement with the wider community outside of the service would benefit from further development, however, overall people were supported to maintain contact with their relatives, friends and people of importance to them.

Care records did not consistently reflect relative’s involvement in there development. Our findings were confirmed from feedback we received from people’s relatives.

People’s care records did not consistently reflect outcomes of this joint working with health and social care professionals; however, staff and leaders gave positive feedback about partnership and collaborative working with health and social care professionals.

We received mixed feedback from external professionals and stakeholders in relation to the attitude and approach of the provider, staff and leaders in relation to collaborative working. Overall, we were told external professionals and stakeholders experienced difficulties sourcing updates and feedback when they requested this from the service as part of their ongoing monitoring processes.

We identified opportunities for further development in relation to community integration and relationship building to build relationships and support people to feel part of the wider community.

The provider and leaders were not found to be open to our feedback, or that of people’s relatives to drive improvement or changes within the service, for the benefit of the people who lived there.

Where we gave feedback to leaders and the provider as part of the inspection process, we were met with opposition and poor responses which did not assure us the provider and leadership team were open to feedback or willing to implement changes in response.

The service was not ensuring staff learnt from incidents and accidents, and that required levels of improvements were made to reduce the risk of reoccurrence. Action was not being taken to protect people or staff from harm as an outcome of learning from incidents.

Action was not taken in response to findings from audits and checks completed to drive improvement at the service, and the governance checks in place had not identified the level of risk and failing found during this inspection.

The provider marketed 8 Acres as a ‘specialist residential service for people with learning disabilities and autistic people.’ However, we did not identify any examples of innovative practice, we did not identify investment in developing and up-skilling the staff team to reflect the specialist nature of service purported to be provided.