Dimensions Fountain House Innox 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

In this key question we looked at 1 quality statement. We looked at the provider’s systems and processes in relation to the management of the service. We found audits were completed regularly and the feedback from staff about the management team was positive. However, we found a breach of legal regulation in relation to governance. Audits had not identified the concerns found during this assessment and the provider failed to ensure people had accurate, complete and contemporaneous records.

This service scored 71 (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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 described the manager as having great strengths, and that they would “commend and applaud [manager] for being an amazing manager”. However, staff felt the manager does not always effectively address concerns, telling us: “Sometimes [manager] can be too gentle with staff we have a problem with, and she'll [speak with staff] but the member of staff continues to upset others, so it continues.” Another staff member told us: “[The manager] is really good, I have great respect for [manager], but I don’t think a lot of staff appreciate her or her position.”

The systems and processes in place to ensure good governance were not effective in identifying the concerns we found during our assessment, as referenced under the Safe key question. For example, the service’s medication audit did not identify the concerns we found during our site visit in relation to the transcribing of medicines, despite the person, who completed the audit, had recorded they had checked the details on peoples' medication administration (MAR) charts as ‘correct and up to date’. We found one quality audit which had taken place last year, which identified that a person’s care and support needs were not clearly documented around eating and drinking. This had not been rectified despite being recorded as a completed action, as we also identified this during our assessment of the service. We raised this with the manager during feedback, but the manager did not provide us with assurances this would be amended.

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.