OLIVE ROW CARE HOME

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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

The provider failed to have clear and effective governance, management and accountability arrangements. The provider failed to have processes to ensure that learning happened when things went wrong. Staff and leaders did not have a good understanding of what was required to ensure people’s care and safety improved. Staff and leaders did not always demonstrate a positive, compassionate, listening culture that promotes trust and understanding between them and people using the service and is focused on learning and improvement. We were not assured that leaders had the experience, capacity, capability and integrity to ensure that the organisational vision was delivered, and risks were well managed. The provider failed to have a system for staff at all levels to raise their concerns without fear of reprisal.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders did not always demonstrate a positive, compassionate, listening culture that promotes trust and understanding between them and people using the service and is focused on learning and improvement. The trainer had been tasked with raising care standards with staff. They described staff as, “A good group, caring. Now there was good management.” Staff told us, “With the chopping and changing of managers, it’s been difficult, with different approaches.” They described the constant changing of managers had led to a lack of consistency and poor practice.

The provider understood there needed to be a structure implemented and embedded to have effective managerial and clinical oversight of the service. The new manager was undergoing their induction, however, they had been given a great deal of responsibility. Effective systems needed to be implemented which would take time to embed with the staff to ensure the quality and safety of the service. The provider had implemented an action and improvement plan following the assessment and enforcement action taken by CQC.

We were not assured that leaders had the experience, capacity, capability and integrity to ensure that the organisational vision was delivered, and risks were well managed. Leaders were not knowledgeable about issues and priorities for the quality and safety of the service.

The provider failed to provide and ensure there was a team of capable leaders that had the capacity to oversee the implementation of new systems to improve the service. The provider had placed an area manager in the home to manage the service in the interim, whilst recruiting a new manager and a clinical lead. The manager had only been employed for a matter of days before our onsite assessment. There was no stable management of the service that understood the needs of people, knew the staff or had a clear vision of what was required to improve the service.

Staff and leaders did not actively promote staff empowerment to drive improvement. They did not encourage staff to raise concerns or promote the value of doing so. Staff were not confident that their voices would be heard. Staff attended staff meetings which were primarily to share information about conduct and practice. However, there was not enough communication between leaders and staff about people’s conditions, their behaviours and the consequences of staff not being confident in managing peoples care and support needs.

The provider failed to have a system for staff at all levels to raise their concerns without fear of reprisal. There was not a culture of listening and learning from staff experiences, and staff were not involved in the service improvement plan.

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 failed to have clear and effective governance, management and accountability arrangements. The provider had failed to provide enough resources to manage the changes required to improve the service and to oversee the management and clinical safety of the home. The management team struggled to update people’s care plans, carry out audits and take the necessary actions, train all the staff and test their competencies and maintain smooth running of the home.

The provider failed to have systems in place to manage current and future performance, or systems to manage risks to the quality of the service. Systems, processes and audits that had been implemented had not identified the issues found during the assessment including the lack of clinical oversight of medicines, wounds, nutrition, unexplained injuries and delivery of care. There had not been enough managerial oversight of the training of staff, testing of their competencies and records of care. Care records that were written on paper, did not include people’s names or room number which meant the provider and manager would not be able to effectively audit people’s paper- based care records once they were removed from people’s bedrooms each week. The provider failed to have a system to review people’s experiences to ensure they were receiving care that met their needs.

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.

Staff and leaders did not have a good understanding of what was required to ensure people’s care and safety improved. On 18 March 2024 we advised the manager of our concerns that people had access to substances and products that could be harmful such as thickening powder for drinks. The manager failed to act on this immediately and it was raised a further time with them. On 20 March 2024, we continued to find the thickening powder was stored in the same unlocked cupboard in the dining area. Although staff were careful to lock the thickener away the rest of that day, people continued to be at risk of serious harm as there was not a sufficient system in place to ensure drinks thickener was out of reach of people living with dementia who may ingest this, risking serious harm.

The provider failed to have processes to ensure that learning happened when things went wrong, and from examples of good practice. Leaders did not encourage reflection and collective problem-solving. The provider failed to have effective processes in place to learn, improve and innovate. Following the assessment, the provider was open to the feedback received and commissioned a consultant to work with them, the management team and staff to evaluate the governance of the service and assist with the implementation of the required improvements.