1 Think Local Act Personal Quality Forum 15 September

Adult Social Care services to be inspected and rated 2 Number of registered services as at 28 June 2015 Type of service Total number Residential services16,914 Community services8,445 Hospice services223 Total25,582

Current ratings overall and by key question 3 Source: Ratings data extracted 11/09/ services rated at September 2015

Ratings by service type 4 Source: Ratings data extracted 11/09/2015

5 Analysis of Outstanding/Inadequate ratings for Well-led

Themes from Well-led: Outstanding 6 CQC Published reports – sampled for data on well-led in mid June. Sample size 50 services with outstanding ratings (all outstanding ratings for well-led when the sample was extracted).

Themes from Well-led: Outstanding sample only 7 Themes common to outstanding services in the sample include: People who use services, relatives and staff speak highly of the service. Effective monitoring, quality assurance and audit systems. Open culture - people who use services/staff/relatives given the opportunity to share views and any issues are addressed. 75 per cent of services had a registered manager in post consistently, and that manager is supportive of their staff. Good leadership extends beyond the manager and includes the provider. Passion Excellence Integrity Cooperation CQC Published reports – sampled for data on well-led. Sample size 177, 50 services with outstanding ratings (all outstanding ratings for well-led when the sample was extracted) for and 127 for services with inadequate ratings for well-led.

Themes from Well-led: Outstanding sample only 8 Effective systems in place for managing and developing staff. Safe care actively promoted – effective oversight of care and staff communication A can do, will do, attitude. Effective partnership working. Culture of continuous development of the service/manager/staff with best practice being followed. Service and/or staff being recognised through national or local awards. Strong links with the local community in just under half of the services. “This place is brilliant, management care so much as do the staff, everybody knows their role and the atmosphere is amazing.”, “I’m made to feel important, I’m constantly encouraged to always better myself.” and “I love it here, I was given this opportunity to make a difference in people’s lives and I’m so thankful for the manager for that.” Passion Excellence Integrity Cooperation CQC Published reports – sampled for data on well-led. Sample size 177, 50 services with outstanding ratings (all outstanding ratings for well-led when the sample was extracted) for and 127 for services with inadequate ratings for well-led.

What makes a service Outstanding? Examples of well-led services 9 One member of staff told us ”The service has eight values which are focused on the person”. Staff were also keen to tell us “good things about the service are the activities and the support. It’s great to see the reaction of people after they have been somewhere new. People want to move out because they are ready. The service has built their independence and confidence around other people”. There was a culture of openness in the home, to enable staff to question practice and suggest new ideas. The service used ‘thinking meetings’ to enable all to raise or to explore dilemmas. Everyone was then invited to help find solutions. We saw there was little staff turnover and it was a settled staff team. Staff had been working with the same person for a number of years. The service worked hard to match people with staff and we saw one member of staff had been caring for the same person for over three years. Where there were to be staff changes we saw people were consulted in writing and were involved in the process. We found that vision and values were imaginative and person- centred and made sure that people who lived there were at the heart of the service. The home worked with various colleges and schools and give work experience to student’s placements and work experience including the Prince’s Trust. The registered manager also went to local schools to talk to them about the home and about older people in general and discussed ways the young and old can help each other. Follow up visits were arranged and young people were encouraged to visit and take part in activities and planned events. This encouraged and supported community cohesion. The service was actively working with other organisations to contribute to research about the design and delivery of more effective and relevant home care services. This work had resulted in the setting up of a six months pilot project. The project provided emergency care for people if their family carer became unwell and unable to cope and the person may otherwise have been admitted to hospital. The aim of the project was to identify a possible unmet need for this service and decide at the end of the pilot if funding this type of service would achieve better outcomes for people living in the community. The manager’s knowledge of underpinning research and best practice in dementia care included an understanding of how environmental design impacts on people. This included the lighting, décor, colour scheme, and flooring being reviewed not only for safety but in terms of the effects this has on individual’s behaviour. The manager’s philosophy of care for the service : “We keep people active and engaged and find new things for them to do so they can have a better quality of life” and, “We have a programme of life enhancement and inclusion that we have worked on for 27 years and have never stopped. That’s why people want to look at our model of care”. The managers’ ethos was reflected throughout the service with staff being observed reassuring people using the contented dementia learning and having conversations with people without asking questions which helped people be calm. CQC Published reports – sampled for data on well-led. Sample size 177, 50 services with outstanding ratings (all outstanding ratings for well-led when the sample was extracted) for and 127 for services with inadequate ratings for well-led.

Themes from Well-led: Inadequate sample only 10 CQC Published reports – sampled for data on well-led. In mid June. Sample size 127 services with inadequate ratings for well-led.

Themes from Well-led: Inadequate sample only 11 Themes common to inadequate services in the sample include: People who use services and their relatives speak of continuous management churn and change. Poor care planning resulting in lack of personalised care. Closed culture - people who use services/staff/relatives feeling unable to raise issues or their views not listened to or acted upon. No registered manager or, if in post, unable to lead and support staff effectively and consistently. Poor oversight of care with care plans not up to date, reviewed or followed. CQC Published.

Themes from Well-led: Inadequate sample only 12 Ineffective systems to identify and manage risks and learn from mistakes. Lack of supervision and training opportunities to develop staff skills. Poor working relationship between the manager and the provider. Under developed partnership working and community links. Unawareness of best practice. Notifications to CQC not being made. CQC Published reports – sampled for data on well-led. Sample size 177, 50 services with outstanding ratings (all outstanding ratings for well-led when the sample was extracted) for and 127 for services with inadequate ratings for well-led.

What makes a service Inadequate on leadership? Examples of services 13 The manager was being supported by a regional manager and a registered manager from another home. However, it was clear when speaking with the regional manager and the manager that they did not have a working relationship that had identified the challenges and risks faced by the home. There was no structured process which identified how they would work together to improve the service that people received. We saw the manager did not have access to all of the computerised systems which restricted them being able to carry out their role. The registered manager and staff did not know what the aims and objectives of the service were when we asked them. The provider did not have a clear set of values and behaviours they required from their staff. The registered manager and the provider were not aware of the shortfalls in the quality of the service found at the inspection. Records for the house meetings did not show the names or numbers of staff that attended the meetings. They demonstrated that a wide range of topics had been discussed and that staff had been kept up to date on a range of matters. Whilst a staff member told us they could have their say at meetings, minutes read like a list of instructions and there was limited evidence that staff views had been sought. We saw examples of recurring incidents involving the same people and staff, but there had been no changes to the way that care was delivered to this person and no evidence of learning from these incidents. The incident report forms were all kept within people's care files with no central accident and incident log for any incidents to be reported in. This meant that there was no easy way for staff to monitor any patterns in accidents and incidents and they were not able to learn from any incidents that had occurred. During our inspection we were also unable to evidence the role they (the registered manager) played in managing the registered service. Minutes of a recent board highlighted their focus on securing partnerships, referrals, completing proposals for funding, developing networks and involvement in projects to improve people’s employability, as well as overseeing a young people’s service. The minutes also reflected the registered manager’s directly saying they were struggling to find time to commit to all their responsibilities. People’s care was planned and reviewed by the registered manager without the involvement of staff, who provided people’s care, and without involvement of people themselves. Reviews of care records had not identified the shortfalls in assessments, care planning and care delivery that we found. Some of the people we spoke with raised concerns with us about the quality of the management at the home. One person said; “I don’t know the manager.” Another said, I know who the manager is, I can recognise them by their pinny [pinafore]. However I don’t know their name.” A relative said, “The managers change here, no one has stayed. I don’t know if they’ve got a manager now.” The registered manager did not have the skills and knowledge to lead the staff effectively. Staff had not received information and guidance about how to provide safe care to meet people’s individual needs. A deputy manager worked at the service, they were not clear about their management role and responsibilities, and told us, “I am more of a glorified carer”. CQC Published reports – sampled for data on well-led. Sample size 177, 50 services with outstanding ratings (all outstanding ratings for well-led when the sample was extracted) for and 127 for services with inadequate ratings for well-led.

Principles underpinning our strategy development A process of coproduction 1 1 Focused on a future vision of quality regulation 2 2 Considering the role of regulation versus other drivers of quality 3 3