P.S We Care Ltd

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

Well-led

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this registered service. This key question has been rated Good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider was passionate about their vision for the service and ethos of care ensuring people were at the centre of their care. This was shared by the provider across the staff group. Staff told us the importance of person-centred care and ensuring people felt cared for and respected This was confirmed by the positive feedback we received from people and relatives.

The provider promoted a culture of openness, diversity and inclusion within the service. Staff were able to approach the provider if they had any concerns to raise and were encouraged to understand and learn people’s diverse needs and that people may need their care providing differently to meet their needs in a way that suited them.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

At the time of the inspection there were 2 managers registered with CQC. The provider had registered as a manager due to the other registered manager being away from the service. The provider and the management team had a clear oversight of the service to ensure people received consistent and safe care based on their individual needs.

People and relatives spoke positively about the provider. One person said, “The registered manager is really nice, I have spoken with them, and they are always helpful.” A relative said, “I’m happy, I approach [Provider’s Name] as they are very helpful, and they have been really empathetic to my relative’s situation.”

Staff felt supported by the provider, who was visible and approachable. Staff felt valued in their role and an integral part of the service. Regular ‘thank you’ letters were sent to the staff team, and staff were nominated for awards. One staff member said, “[Provider’s Name] is approachable both personal and work wise.” Another staff member said, “I feel very supported in my role and all staff appear to be happy working here. I feel genuinely appreciated.”

The provider understood their responsibilities of their registration with us. They had notified us of events that had occurred at the service and were open and honest when things went wrong, responding to feedback as they were continually looking for ways to improve the service for people. The provider said, “It’s important we receive feedback about the care people receive because it gives us a chance to make changes and improve. I’m always looking at ways to learn and improve.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff understood how to speak up and told us they were able to raise concerns easily and approached the Deputy Manager or Provider when needed. Staff understood how to follow the provider’s whistleblowing policy, which was accessible to them. One staff member said, “I would always go to management if I had concerns, but I know if I didn’t feel listened to, I could whistle blow to CQC.”

Team meetings were useful and provided an opportunity for staff to raise practice related issues and discuss ways to improve. One staff member said, “Team meetings are useful, we discuss any improvements needed and updates. [Provider’s name] always ends on a high and shows appreciation to the staff, which is good for staff morale.” The records we viewed confirmed what staff had told us.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider promoted a diverse and inclusive workforce, ensuring all people are treated in a fair and equal way. The provider has encouraged recruitment to ensure a diverse workforce and respects the individual needs of all staff. Staff are encouraged to attend events that are important to them such as religious and LGBTQ+ events and made reasonable adjustments to accommodate this time away. The provider said, “I ensure all my staff are treated fairly and never discriminated against. Our core values mean so much to me and this is one of the top values I have.”

Staff told us they felt treated in a fair and equal way by the provider, management team and all colleagues they work with. One staff member said, “We are all respectful and treat each other in a caring way, we are like 1 big family.”

The provider completed regular supervisions, appraisals and spot checks which enabled them to discuss any issues within their role and to promote continuous learning and development.

The provider had clear responsibilities, roles and systems of accountability; however, some improvements were needed to ensure the systems in place were consistently effective in identifying areas of improvement required.

The provider had governance systems in place to monitor the service and identify any shortfalls which required improvement. However, we found that improvements were needed to ensure the Medication Administration Record audit contained details of the action taken when errors had been identified. Improvements were also needed to ensure all records contained accurate and up to date information, whilst ensuring the audit in place to monitor care records was effective in identifying errors. We fed this back to the provider who acted on the feedback immediately.

There was a clear management structure at the service and there was an action plan in place to identify actions required within a timescale to continually improve the service provided.

The provider had a contingency plan in place to ensure people continued to receive their care when events out of their control happened, such as adverse weather. Staff were aware of this and understood when changes may be needed to the way they worked to ensure continuity of care.

Records we viewed such as team meetings, supervisions and ad hoc correspondence to staff demonstrated the provider regularly shared good practice guidance and updates in the required standards of care with staff. This ensured staff had the most up to date information to follow when providing care to people.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider developed good working relationships with a range of professionals to ensure people received consistent care and their needs were reviewed when needed. This included of health and social care professionals to ensure people’s care needs were discussed to provide joined up care.

The provider was open to feedback from other professionals to help continually improve the service people received and was passionate about the importance of learning from feedback. The provider said, “I welcome any feedback from other professionals, like CQC too as I am always looking at ways to improve how we do things. It’s important to me that we are providing the best service we can.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff told us the provider encouraged them to develop their skills and knowledge to assist them to support people effectively. One staff member said, “[Provider’s name] is always introducing new training, and I am pushed to excel in my career.”

The provider reviewed incidents, accidents, safeguarding and complaints to share learning and good practice with staff which ensured improvements were implemented when needed.