Personalized Care Plus Ltd Office

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.

This is the first assessment for this newly 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.

Management promoted an open and transparent culture, providing individualised care and support. Staff felt valued and supported by the provider. Professionals were complimentary about the staff and management, comments included “The amazing care they [staff] deliver in a very challenging environment. They [staff] truly do care” and “Management were very open and accepting of feedback.”

People were happy with the service. However, 2 people felt that communication was not always effective. We discussed this with the registered manager, who agreed to take action to address this concern.

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.

We found management to be passionate and enthusiastic about the service and responsive to information we requested throughout this inspection. Staff told us they found the management team approachable and supportive. A staff member stated, “Management are approachable, they lead by example, they will come out and support to care for clients and are very supportive.” Management ensured service delivery was individualised to meet people’s specific needs.

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

Staff expressed feeling confident in raising concerns and believed that the registered manager would respond appropriately and take action when needed. The registered manager maintained a supportive environment where staff could openly share ideas, raise concerns, and suggest improvements directly with them. A staff member said, “I feel there is a positive culture where staff can speak openly about concerns or improvements. When concerns are raised, management generally listen and take appropriate action.”

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 were supported in their development through regular supervision, team meetings, and ongoing training, fostering a positive and inclusive working environment. Policies promoting equality and diversity were embedded within the workplace, helping to ensure that staff felt valued, respected, and well supported to perform their roles effectively.

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. However notifiable incidents were not always reported to CQC.

During this inspection, we identified that the registered manager had not consistently notified the CQC of significant events within the required timescales, as set out in statutory requirements. We raised this with the registered manager, who acted promptly to address the issue and submitted the outstanding notifications retrospectively.

Systems were in place to learn from incidents, to prevent reoccurrence of incidents. Care call monitoring was undertaken to provide the registered manager with an oversight of service delivery. The provider had a business contingency plan in place to ensure service delivery during emergencies such as adverse weather conditions and workforce shortage. The quality assurance annual report showed feedback was sought for example from relatives, staff and commissioners, providing them with an opportunity to feedback to drive improvements as required.

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.

Professionals told us Personalized Care Plus Ltd Office worked collaboratively with them to achieve good outcomes for people. A professional said, “Carers are open to health professionals’ input, engaging on visits with professionals and welcoming of joint visits. Carers respond to feedback, if I have observed anything I feel needs attention such as moving and handling.”

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 had processes in place to promote learning and improvement. An improvement action plan supported continuous service development. The registered manager was receptive to feedback and took immediate action to address and clarify issues identified during the inspection.