PCAS Kent 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 – 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.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to 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 75 (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 results of the staff culture survey showed a number of actions including ‘We have created a culture steering group to work through areas of opportunity within our culture.’ The provider communicated that they would continue to drive person centred support and collaborate across departments and to create a shared set of unique PCAS values underpinned by our shared purpose.

The provider had developed company values since the last assessment. These were: Act with kindness and respect, Care, Open to ideas, Honest and transparent and Empowerment. These values and the wider explanation of each of these had been shared across the organisation and embedded.

Most staff told us there had been a change in culture in the last year. Staff said, “It feels like a different culture now”, “I think the work we have done since the last inspection is massive, we wanted to improve. The change has been massive. The culture has changed 100%. I think the staff feel happier”, “Culture has got better, I feel we get listened to” and “It is an open culture, we can speak freely and they listen. We often discuss how to support our guys better.”

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.

Since the last assessment the provider had restructured the management team. Senior managers including the directors were actively involved in the day to day running of the service and had good oversight of any changes, issues or good news. Staff reported that this had improved communication, information flow and responsiveness. We observed people actively engaging with members of the management team both in their homes and at the provider’s offices.

Staff said, “Communication is much better, HR and Ops [operations] managers come to meetings and are more involved. Staff find this better”, “From what I have seen [nominated individual] and [director] are proactive and involved” and “A lot has changed, communication is 100% better, so much has improved, we as a team have worked to get it improved. The management side has improved, we work as a team now, we are being heard and listened to.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistle blowing policy in place. The staff survey results showed that 86% felt confident with the whistleblowing process.

A staff member said, “The biggest changes are across the board we get feedback about what is being done. I would be comfortable to whistle blow if I needed to.” Another staff member told us, “They [directors] would do the right thing.” Other staff commented, “We have been advised about whistleblowing with all the numbers in the house. I am very confident if I had to [call it] but I never had to which is good. If I had a concern, and I thought the manager couldn’t deal with it, I would go to the ops manager. Honestly, I would go to the whistleblowing number as I’m more confident it would be dealt with” and “I know that whistleblowing is a policy that allows a staff member to report unsafe practice it would be confidential” and “I’m very confident to whistle blow we even have the number on our payslip.”

The provider had a complaints process in place and were able to demonstrate how they had investigated and responded to complaints. A relative said, “I have not had complaints, if I had I’d be listened to and acted upon.” Another relative told us, “No complaints about them. If I say something little, it’s actioned and not sat on.”

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.

Most staff told us they felt well supported and they felt communication was good. The provider sent out a weekly communication to staff to keep them updated of important information, news and events across the service. The provider promoted staff wellbeing and supported inclusion through regular team meetings, social events and ongoing support from managers. Staff were supported to gain recognised qualifications.

The provider had developed menopause cafes which ran when required (when staff sought support) and had put in place menopause passports. There was an inclusion calendar of events which took place monthly. These included, walking challenges, the service celebrated work mental health day.

The HR team ran support sessions with managers and team leaders in key areas such as supervisions, appraisals, probation, policy, best practice and experiences and neurodiversity sessions. The HR team worked closely with training and development team to enhance support for managers.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The provider and the management team had good oversight of the service. Audits and checks were in place; the provider had an action plan which they continuously monitored to check the status of actions from audits.

Audits had been carried out of daily records, care plans, finances, staff communication, handover, medicines, accident and incidents, health and safety, fire, PPE, COSHH, (Control of Substances Hazardous to Health) and infection control. Operational managers carried out observational audits of staff practice when they worked with people in shared premises (supported living houses).

The provider had policies in place which staff had access to in hard copy at the service or electronically through individual log ins.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. We were assured that incidents had been appropriately reported.

Where audits had identified actions, actions had been recorded and the management team had signed off items that had been addressed.

Services that have received a rating are required to publish their rating on their website and within the service. The provider had displayed their rating in line with the regulations.

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 worked closely with people, relatives, staff, health and social care professionals including community nurses, mental health services, social workers and occupational therapists. Information was shared appropriately to ensure care remained responsive to people's changing needs and to support continuity of care.

The provider also worked with external training providers and sector partners to develop staff knowledge and skills as well as their own training and development team. This helped to ensure staff were equipped to provide safe, effective and person-centred care. Through partnership working and information sharing, the provider contributed to improving people's experiences and achieving positive outcomes.

The provider held events with partner agencies to support people’s learning and understanding of health, safety etc. For example, the service had hosted a safety day where people got to learn about how to stay safe from a variety of agencies including the local police. People were invited to events in their local community and to events held at the provider’s offices. On day 2 of our office site visit a bake-off event took place, some people attended with cakes and biscuits they had made with support from staff if they needed it. Staff who worked in the offices were also involved producing goods. The event raised money for charity.

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.

The provider told us they were part of local provider networks and forums, where providers and registered managers shared best practice, discussed challenges and supported one another. They also attended relevant webinars, training events and sector updates to keep their knowledge current and ensure the service responded to changes in legislation, guidance and best practice.

Since we last inspected the service quality has improved. Health and social care professionals also commented on this. They said, “There have been visits to the Individual’s homes by the quality and standards teams and by our social care colleagues last year and more recently by our focused review team and reports overall are positive. Communication has improved between the provider and the council, and this brought learning to all parties and collectively the issues have been worked on over the last year” and “I meet regularly with PCAS managers and can see the efforts that they have bene putting into all services to make improvements, they listen to guidance and advice while maintaining challenges where they are able to demonstrate evidence to support requested changes. Their training offer has grown and from recent involvement staff retention is great meaning relationships can be formed.”

The provider and management team told us they had reviewed the feedback we gave them as part of the onsite and offsite assessment process and valued this. They were using the feedback to make improvements to the service and to put systems in place to embed the changes. Areas discussed at the assessment site visit were added to the action plan for the organisation in a timely manner and the provider updated CQC on the progress of these actions.