St Oggs

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 assessment we rated this key question requires improvement. At this assessment the rating has remained as requires improvement.  This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.  The service was in breach of legal regulation in relation to good governance. 

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.  People at the service told us they felt respected. Overall people and staff said that the registered manager was approachable. We observed staff and the registered manager were compassionate towards people.

The provider had not ensured the registered manager had capacity to ensure the organisational vision could be delivered, risks were well managed and that they had support to ensure the quality of the service. The registered manager knew the service and the people they were supporting. However, they did not have the protected time to concentrate on the governance of the service. Additionally, the providers internal quality assurance systems had not identified issues found during this assessment.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.  The registered manager fostered a culture of an open-door policy where people and staff could come to them with any concerns. Staff told us they would raise concerns as and when they needed to and that they felt they would be acted on. Staff were aware of the providers whistleblowing policy

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. All staff we spoke with said they were treated fairly by the registered manager, management team, provider and other staff.

The service had clear responsibilities and roles. However, the registered manager was not given protected time to carry out their roles and responsibilities. The provider’s systems of accountability had not identified shortfalls in governance. The providers policy to include the registered manager into the numbers at the service meant the registered manager was often working additional hours. The regional manager visited the service monthly and completed reviews of care records and audits. Actions they identified were not always effective in driving improvement at the service. For example, in identifying where care records did not provide enough guidance to staff. As well as not identifying, when the service had not recorded incidents and accidents well, they were also not using the most up to date form to record accidents and incidents.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and collaborated with partners. People at the service benefited from the partnerships that the service had built with local health services such as GP and mental health teams.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. The registered manager was able to tell us about times when they had learned from incidents at the home. For example, there had been a person at the service who had started to show distress towards people at lunch times. The manager had not acted and ensured they attended the dining room themselves. The incident forms did not identify any learning as the incorrect form had been used to document the incident. Additionally, when a person had started to have falls at the service incident forms did not identify learning. The person was moved from an upstairs bedroom to a ground floor room to reduce risk, even though all falls had been on the ground floor.