Bobbins

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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 service was not well led. Provider and management systems had not been effective in keeping people safe and ensuring they received high quality care and respectful care. They had not identified inappropriate use of restrictive practices, poor staff culture, lack of staff training, concerns with medicine management and recruitment issues. Systems had not recognised patterns of incidents which could be a sign people were at risk of abuse. Throughout the assessment the provider and management were open to challenge and responsive to our concerns. Although, the provider was receptive to CQC concerns they did not have sufficient oversight required to keep people safe. They told us they wanted to drive improvement including their own internal investigation into how the poor state of the home had occurred. By the second site visit improvements were observed. Although it was too early to know if they could be sustained. For example, some staff appeared more confident and respectful to people, action had been taken to improve incident reporting and analysis.

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.

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 had a good relationship with the registered manager and felt supported. Although there was reliance on the registered manager to attend any incident that occurred.

Systems were not effective at provider level to support the registered manager running the home. The provider and management systems had failed to identify the poor culture and inappropriate use of restrictive practices in the home. The registered manager lacked knowledge to support staff effectively with the needs of the people. We raised our concerns with the provider who informed us they would take immediate action. By the second site visit, the level of support by the provider had increased. This included regular visits from internal specialists to support with things like medicine management, care plan writing and quality monitoring. The registered manager told us how much they appreciated this increase in support.

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.

Staff did not feel they had enough training to provide safe, respectful and quality care in line with current best practice. Neither were staff consistently using the systems in place to support people in the best way they could and report concerns. We raised our concerns with the provider. By the second site visit, staff were more positive about the systems and training they were using. They felt better equipped to support people safely and with respect.

Systems had failed to ensure people received safe and high-quality care. Concerns were found during the assessment that the provider and management had failed to identify. As a result, people were at risk of being harmed or receiving poor care. This included not having suitable, well-trained staff to protect people. Medicines were not always being managed safely. Recruitment had failed to be in line with legislation. Additionally, the provider’s policies were not being followed by staff or the management. We raised our significant concerns with the provider who responded positively and wanted to make improvements. They acknowledged changes needed to be made and worked with the regulator to ensure these happened. It was too early to state whether these improvements could be sustained.

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.