Greenacre Park

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

We identified a breach of the legal regulation, good governance. The provider’s governance systems and audits were not always effective in identifying or addressing areas for improvement. Although the service engaged in partnership working, we received mixed feedback from professionals and our observation was the service was not always effective at promoting positive outcomes for people. Staff shared positive feedback about the management team. Staff told us they felt able to speak up if they had concerns. The provider was working with stakeholders to identify and address areas for improvement. The need for improvement was acknowledged by the management team.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There wasn’t always a positive culture within the staff team. We received mixed responses from staff. One staff member told us, “Some staff lack insight, I don’t know whether it's because they have no idea or they don’t know what they're supposed to do. They need more insight into why we are doing it, not just come to work, but treat the service users the way you want to be treated.” Another staff member said, “My concern with the new staff starting is that they will learn the poor standards of the current staff members and not the standard expected.”

We saw evidence of changes the new management of the home were making. We saw how they were holding meetings to share information which included meetings between managers, the provider and the staff team. One manager told us, “We are looking to openly discuss the closed culture and how to identify this, we have discussed in supervisions.” However, this was not yet embedded in practice.

Most staff told us they now felt confident to raise concerns with the management team and these would be listened to and acted upon. A staff member told us they did not always feel listened to in the past. The provider told us they asked for staff feedback and would address any concerns raised with them.

Due to recent concerns, the provider's management team were visible daily at the service. They were overseeing improvements designed to improve people's safety and well-being. The provider had also deployed additional staff whilst a review of the service took place.

Staff generally told us they felt able to raise concerns. The management team were working to be more visible within the service and enable staff to have access to the knowledge and information they needed to provide safe and care and support to people.

The provider had policies and systems in place, which aimed to foster a culture where people felt they could speak up and that their voice would be heard.

The management team told us staff completed equality and diversity training and they employed and supported a diverse workforce.

Training, policy and procedures were in place to support equality, diversity and inclusion. The service had a multi faith room designated to staff which we observed being used frequently throughout the assessment.

The provider and management team told us about the audits they undertook.

The provider's quality monitoring systems had not been used effectively to ensure improvements were identified and acted on quickly. The provider had also not consistently created a learning culture at the service which meant people's care did not always improve. For example, care records were not always accurate, and staff did not always follow guidance in people’s care plans.

People told us they frequently enjoyed the activities on offer at the service. One person told us, “I have been out quite a lot. Been to the cinema, it was good I quite enjoyed it.” However, there was a lack of consideration in activities for those who wished to remain in their rooms. One relative told us, “I really don’t know what he does all day, they never tell me.”

The management team told us how they were engaging with external stakeholders to improve the service following some recent concerns.

Professionals shared their concerns with us around stimulation, staffing numbers, care records and communication which they felt impacted people living at the home. Feedback from the local authority was that the provider had been engaging and was working on implementing improvements.

The provider had systems and processes in place to engage with external partners.

The management team acknowledged the concerns and failings found on the assessment and were open and transparent with their response and desire to improve the service. The management team acted on feedback we provided from the onsite assessment immediately and we saw evidence that these concerns had been communicated to staff with an appropriate action plan to support development, changes and improvement.

Processes and procedures were ineffective in ensuring continuous learning, innovation, and improvement within the service. We identified shortfalls in internal audits and analysis which failed to reduce the likelihood of accidents and incidents reoccurring.