Delrose

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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

We assessed 5 quality statements in the well led key question as part of this assessment. These quality statement scores have been combined with scores based on the rating from our last inspection, where the service was rated requires improvement. The overall rating for this key question remains requires improvement. We found concerns where a breach of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was identified in governance. The service had lacked consistent, strong and effective leadership. There was not a registered manager in place and relatives and staff felt this had a significantly negative impact on the culture at the service, performance of staff and the quality of care. Systems to oversee and improve the quality of care were not effective and there were limited auditing processes in place to support identifying shortfalls and promoting improvements.

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 were not clear about what the visions and values of the service were. They said they had 3 managers in the past year overseeing the service, which made it difficult to sustain and embed a consistent approach, direction or culture. The area manager acknowledged those changes to management had contributed to confidence staff had in the leadership team. However, they told us the provider had taken steps to address this by recruiting an interim manager and by basing the area manager at the service.

The provider had a statement of purpose which outlined the visions aims and strategy of the service. However, the absence of consistent, sustained leadership had impacted the provider’s ability to assess or monitor the day-to-day culture of the service, which had contributed to an inconsistent experience for people receiving care.

Staff told us there had been a number of different managers in place, who had not stayed for a sustained enough period to make consistent improvements or provide stability and assurance. They told that this had a negative effect on the service as issues were not always addressed, which had resulted in examples where people did not receive effective support. The area manager acknowledged that the provider had experienced difficulty in recruiting and retaining a consistent and stable management team but were confident in putting an effective team in place to oversee the service.

The service had not had a registered manager in place since December 2022. Since this time there had been a number of different managers who oversaw the service, with none staying a significant amount of time to enable them to create a positive culture or drive sustained improvement. The service was being overseen by the area manager. During the assessment, the area manager confirmed the provider had employed an interim manager who would be based at the service.

Staff felt they could raise concerns and were aware of the provider’s whistleblowing policies and procedures. However, some staff also told us they didn’t always get feedback from any issues raised. The area manager told us how they were improving the opportunities for staff to speak up and voice their opinion. This included individual and group meetings with staff and training for staff to ensure they knew how to raise concerns.

The provider had whistleblowing policy in place. This detailed how staff could raise concerns internally to the provider and the external bodies they could escalate concerns to.

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.

Staff told us that frequent changes in leadership meant there was limited management oversight and a lack of consistency in how the service was overseen. The area manger acknowledged the challenges that the service had faced in recruiting and retaining a stable management team. They told us that the provider had arranged for an interim manager to oversee the service whilst they recruited a permanent registered manager. The area manager was also based at the service to support the interim manager when they commenced their role.

The provider had failed to put in place an effective governance system to oversee and improve the quality of care and safety of the service. There were auditing systems in place, but audits were not consistently carried out and actions identified were not always followed up. Some audits were not effective in identifying issues or driving improvement. For example, the provider had an internal quality audit completed in February 2024. However, this audit did not pick up issues around quality and safety identified at this assessment. There was not a clear governance structure in place, which contributed to shortfalls in the quality of care, a lack of clarity and accountability as to who was responsible for key tasks in the day to day running of the service. This included tasks around monitoring staff training, overseeing staff recruitment, investigating incidents and monitoring staff performance. The provider had a business continuity plan in place. This detailed how the service would run safely in the event of an emergency. However, the business continuity plan did not contain accurate and up to date information, including, the number of people supported and accurate emergency contact details. This reflected a lack of oversight in ensuring emergency planning was clear and robust.

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 told us that there was often no follow up or feedback from incident forms they completed. This meant they were not always clear on follow up actions from incidents and there was limited learning that could be applied to future practice. Staff were not aware of an overall action plan about how the service would improve or the role they had to play in this improvement. This reflected that there was no clear direction or plan about how improvements would be made.

The provider failed to effectively implement plans to drive improvement since our last inspection. At this assessment, we identified areas where quality and safety had deteriorated to the extent where regulations had now been breached. For example, Incidents were recorded by staff, but these were not always actioned by management. There was no evidence of learning from these to prevent similar incidents happening again. In another example, the provider completed an internal quality audit in February 2024. The audit did not identify all the issues we found at this assessment. There was limited evidence about how actions from this audit were followed up or reviewed. This reflected that this process was not effective in driving improvement.