Gillingham Road

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 our last inspection we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulations in relation to processes in place as well as the ethos, values, and behaviours of leaders and care staff did not always ensure people using services lead confident, inclusive and empowered lives. Leaders showed a lack of understanding on how to meet the RSRCRC principles. Quality governance systems were not effective in their use and there was a lack of processes in place to gain feedback to drive improvement. There was a lack of robust oversight and lack of assurance processes.

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.

Quality frameworks did not always recognise best practice and were not effective in identifying short falls in the care people received or gaps in people’s care records. The provider/registered manager told us, “The strategic vision and values are to care for people with care and respect…… ensure that clients and staff are safe whilst carrying out duties.” However, we found leaders of the service did not demonstrate the required experience or capability to deliver person centred care or to ensure risks were well managed. They failed to recognise they had developed a culture that did not robustly promote or uphold people’s rights. We found the provider/registered manager was not always open and transparent with others involved in people’s care [or during our assessment]. This meant professionals and people’s representatives were not always in receipt of information to make an accurate judgement about the quality and safety of the care provided, which put people at risk.

Although staff fed back positively about the leadership, we found the leaders had not considered the impact to staff in working in long and at times multiple shifts. Staff did not have formal breaks, and we found the provider/registered manager had not always considered the wellbeing of staff. The provider/registered manager told us staff were not given formal breaks despite working 12-hour shifts. They told us staff got their ‘informal’ breaks when people were resting. However, all people at the supported living settings were funded to have a member of staff with them throughout the day and people did not have breaks as this was their home. We saw from staff meetings they were not given an opportunity to feedback on any improvements that might need be made. They were also not given an opportunity to complete surveys.

Leaders did not role model a shared vision, strategy or positive culture to staff. This had a major detrimental impact across all areas of people's lives. The provider/registered manager told us in relation to encouraging staff to speak up, “We do have meetings [with staff], we talk about CQC a lot, the expectations of us, say about whistleblowing and if something is not right speak out, raise the alarm even if you may not want to go to the manager.” However, we found the leaders had not encouraged a positive culture where people or staff could feel they can speak up, that their voices will be heard, and their concerns and suggestions listened to. We saw from staff meeting minutes, staff were told they were going to monitored on CCTV in one person’s home to ensure they were performing their role appropriately. The leaders failed to recognise they had developed a closed culture that did not promote or uphold people’s or staffs’ rights.

The service failed to work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff had not received appropriate training in this area and failed to demonstrate good values in relation to equality and diversity. Although staff we spoke with told us they felt they were treated fairly. We found staffs human rights were not respected.

The leaders failed to identify through audits that decision specific mental capacity assessments had not been undertaken in relation to decisions that needed to be made. There was also no evidence of Best Interest meetings where restrictions were in place to determine what other least restrictive measures had been considered. The leaders failed to identify the concerns around staff not taking breaks and working long hours. They were unable to provide evidence of an effective system to assess monitor and improve the quality and safety of the services provided and to ensure they had met the requirements of this regulation. The provider/registered manager told us they had commissioned an audit from an external company in April 2024. However, when we reviewed the audit, they had not considered the recommendations made by the consultant to improve the quality of the risk assessments and recruitment processes. There were no audits of care notes and staff interactions with people. This meant they could not be assured that all areas of service delivery were monitored and that actions were taken to improve poor practice. The provider/registered manager had failed to display their CQC rating on their website which was a legal requirement. They had failed to apply to have a mental health banding added to their ‘Statement of Purpose’ in line with their requirements, despite supporting people with these needs. Leaders were unable to provide evidence of an effective system to assess, monitor and improve the quality and safety of the service which resulted in people having poor outcomes.

External professionals told us they were not always made aware of incidents at the service. They also told us they struggled with any communication with the provider/registered manager which resulted in them having to undertake a visit to a person they commissioned to ensure their safety.

The provider/registered manager told us they only reviewed incidents every 3 months meaning there was a potential to miss where changes could be made to prevent the risk of incidents re-occurring. There was no analysis of the incidents to look for trends, themes and triggers to try and reduce the risk of incidents which placed people at risk. By systematically reviewing incidents services can implement changes that lead to continuous improvement. This might involve revising protocols, enhancing staff training that reduce the likelihood of future incidents. We found this was not taking place.