Newgate Lane

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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 a total of 2 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was good. Our rating for this key question has deteriorated to requires improvement. We found the provider was failing to meet their legal requirements and were in breach of regulation. The provider failed to ensure they operated good governance and oversight of service delivery to ensure processes were being followed. Staff told us that they felt able to speak up and that leaders of the service were approachable.

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.

Staff spoken with all provided positive feedback about the manager and service leader. Staff said that the new manager was professional and had the relevant experience and knowledge to manage the service. Staff told us “The manager listens to feedback and addresses any concerns.” Staff said that the service leader “was very supportive, new to the role but had great potential.” Staff understood the roles and responsibilities of the manager and who to contact in the managers absence.

The provider had recently reviewed the leadership structure to ensure oversight and consistency of service delivery. The Manager was able to access a range of support from the providers internal networks. This included the regional manager, head of operations, managing director, HR & the quality team. The manager had been supported by the provider to complete their Diploma level 5. The manager had an insight into the improvements required at the service and recognised that they needed to be present and have an oversight of the service to achieve outcomes.

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.

Some staff we spoke with raised concerns regarding how well the team worked together. We raised this with the manager who told us that the culture within the team needed to improve and that they had addressed this with the team.

We identified shortfalls in the providers quality and assurance systems. We were not assured the current processes were effective to consistently monitor, identify and embed improvements. For example, we found shortfalls during this assessment in respect of oversight of medicines, contemporaneous and clear records and audits being carried out on a regular basis. The service has a continuous improvement plan however this did not always reflect identified actions and outcomes. This was not always up to date, for example some actions from the internal provider service audits had not been transferred to the continuous improvement plan. Actions included on the continuous improvement plan did not always demonstrate that the target completion date had been met. Overall peoples care plans and risk assessments were detailed to ensure staff knew how they should meet people’s needs, however records were not always updated following identified changes, for example following an incident. Records related to people’s care were not always consistent and the quality and completeness of peoples care records varied. At our last inspection we told the provider they needed to improve end-of-life care and support however these care plans were not in place.

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.