Netherclay 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 inspection we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The provider was in breach of regulation in relation to governance at the service. The provider’s oversight and governance had failed to ensure systems and processes identified the improvements needed in the quality and safety of care being provided. The registered manager and providers were responsive to our findings and started to make improvements during the assessment. However, the improvements made needed to become embedded and sustained

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had governance systems and processes in place to monitor the overall safety and quality of the service. This included audits relating to health and safety, medicines, infection control, risk assessments and people’s support plans. A ‘mock inspection’ by an external company had also been carried out. However, during our assessment, we found people did not always receive safe care and treatment and risks were not always managed safely, due to failings in the management and oversight of the service. The governance systems had not identified shortfalls in risk management monitoring and had not ensured there were enough staff deployed to support people with their care needs. The registered manager did not have a clear system to identify their own priorities. An action plan, devised with the provider, was not meaningful to the registered manager. This meant actions were not always completed, followed through and were not effectively communicated with staff. Staff said there was poor communication, and they were not always kept informed about changes at the home. However, they said the registered manager, was “open and approachable.” The registered manager had 3 recent meetings with the district nursing team. There were no clear actions in response to their concerns or to mitigate further risks. Resident and staff surveys had been completed and evaluated and were positive overall. It was not clear what actions had been taken where concerns had been raised. For example, in relation to a choice of food and staff having enough equipment to provide safe and effective care. The providers had identified some areas of concern prior to our assessment and additional support had been given by the management team from another home in the group. The registered manager and providers were responsive to our findings and started to make improvements during the assessment. However, the improvements being made needed to become embedded and sustained.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.