Gloucestershire Community Support Services

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 Good. At this assessment the rating changed to Requires Improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (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 and manager valued each individual person and evidence showed peoples individual needs were me. Staff and managers had clear understanding of people’s needs and there was a shared culture of wanting people to be able to lead their best lives. For example, one person liked to be able to leave the service very quickly and the managers had put backpacks at all exits so staff could quickly grab them while they followed the person and not restrict them from going when they wanted. We did not find evidence of closed cultures; however, we found some people had unnecessary restrictions which had not been adequately assessed. The manager told us, “What I'm trying to do with the staff team at the minute, I'm trying to action things I'm finding are not correct and build a rapport with staff, so they know I'm approachable. I'm really keen on ensuring staff understand basic, safe, effective care and introducing reflective practice.” The manager had implemented daily spot checks and had ensured staff had up to date job descriptions to review against their practice. The service had a set of core values which were included in the information given to new starters.

Not all leaders understood the context in which The service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The service was run by the manager and 2 service managers, who were all new in post at the time of the inspection. One of the service managers had been with the service for a long time and had been recently promoted. We found all managers spoke highly of the service and wanted to make positive changes to improve the quality of the service. The managers acknowledged some recent failures in service provision but had reflected on why those failures had occurred. Staff spoke kindly to people and were observed to be supportive when people made decisions about what they wanted to do. However, the new management team needed further time to embed practices and ensure they had appropriate oversight of all governance processes.

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

Staff were aware of the term freedom to speak up and felt confident in raising concerns should they need to. One staff member said, “The managers are very supportive, and I feel well trained and satisfied with my job. Communication is very good across the service and staff have an online chat group where they can all connect. I’m aware of the whistleblowing policy and freedom to speak up guardians.” A whistleblowing policy was in place to guide staff on what to do should they have any concerns. A poster on whistleblowing was displayed in a communal area. We saw evidence of staff speaking up during a recent staff meeting.

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.

Staff told us they were treated fairly and the manager told us they supported staff with reasonable adjustments. The service provided staff with several staff rooms across the different sites and had a multi-faith room.Staff had completed training in equality and diversity and there was a supporting policy for this.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service had recently been without a manager and had experienced some failures with service provision in recent months. We found documentation from this period to be inconsistent and not always adequate for maintaining safe standards of care. We found the provider had good oversight of the service generally, but we had some concerns which included how complaints and safeguarding concerns were logged onto the system. The area manager told us a complaint and safeguarding were not logged onto the electronic system which was audited until after an investigation took place. We found although the new manager had recently implemented daily spot checks, these were not being audited. This put the service at risk of not having effective governance. The managers had not had sufficient time in post to make changes; however, they were receptive to our feedback and implemented actions during the inspection to improve oversight and accountability.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider had recently been involved with partner agencies for people who had to leave the service and feedback from the partner agencies was poor. They described the service as being slow to respond to correspondence and failed to maintain the safety of people living there. At the time of the inspection, some improvements had been made, and better relationships were being fostered. We found the service was not an active part of their local community, but this was partly due to the local community not being supportive with integration. For example, the service asked the local parish council if they could decorate a bus stop, but they refused. The service is currently looking at ways to become more involved in the local community including taking over a wildflower garden. Local residents often complained about staff cars parked on the road, but the service was told staff would have to pay to park in the village hall car park next to the service. The service was not adhering to the guidance of Right support, right care, right culture as they had clear signage indicating they were a care provider which is not considered to be best practice for supported living services. Supported living services, in line with the guidance, should not have signage indicating they are run by a care provider as they are people’s own homes. This was fed back to the area manager, who agreed and was planning to take the signage down.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Opportunities to drive improvement were not always recognised. Records were not consistently used to capture people’s experiences. This meant it was more difficult for staff to learn what worked well for people and what did not. While we found some examples of people being supported in a caring and person-centred way, we also found staff had sometimes made decisions based on what was easy or better for staff, rather than the person. For example, staff had been working shifts which supported their preferences rather than the preferences of people they supported. The new manager has rectified this and improved the way shifts are worked. While the service was caring, it was not innovative or pioneering.