Dedicated Care East Anglia Limited

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 outstanding. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service. 

This service scored 36 (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 did not have a shared culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. We found policies and procedures were not actively being followed. We requested several policies from the service to review as part of the assessment and identified 12 policies had been introduced in July 2026, all recorded as version 1. It was not proportionate to expect staff to read, understand and embed all these policies within the same month. We reviewed the previous policies in place, and the provider had implemented their own and there was little to no changes between them. We found the staff were not actively following them. The service's falls policy stated, “staff must Inform the service user’s GP of falls history or recent falls.” There was no evidence of this being followed. The statement of purpose that was provided was inaccurate; however, the provider submitted a new statement of purpose throughout our inspection.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. Policies were inaccurate with the information provided. They recorded that the service provided 2 regulated activities when they only provided 1 and this was recorded in every policy we reviewed. The policies also listed the service user bands they provided as the whole population. This is not correct and questions leaders understanding of the service user bands.

We found a serious injury had occurred within the service and the provider did not submit a serious injury notification. Safeguarding notifications were not consistently raised to CQC when the service did raise safeguarding referrals to the local authority. The provider asked for clarity around when a notification should be submitted as they wanted to be assured, they were reporting notifications appropriately.

Staff did not always feel they could speak up and that their voice would be heard. Freedom to speak up process was not robust. Staff appeared to have a knowledge of when a safeguarding concern should be raised however, they often failed to raise them.

The provider’s freedom to speak up policy referenced who the freedom to speak up guardian was within the service was but their contact details were left blank within the policy. We received mixed feedback from staff regarding freedom to speak up. A member of staff said “I don’t always feel listened to when concerns are raised. Staff have raised concerns on several occasions, but we do not always receive feedback or see actions taken afterwards, which can make it feel as though our views are not fully considered.” Although another staff member told us “I have raised a concern with my own manager before, I felt this was not dealt with exactly how I would like and felt uncomfortable to speak with her again. But [registered manager] in head office was amazing and sat and listened to me.”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Some staff reported difficulties with taking uninterrupted breaks, being contacted during time off, increased workload pressures, and inconsistent management support. A small number of staff felt concerns were not always acted upon, communication could be improved, and recognition varied between services and managers. However, other staff described a supportive culture where they feel valued, respected and recognised for their work. Staff frequently highlighted approachable managers, flexible working arrangements, teamwork and wellbeing support as key strengths. Most felt able to raise concerns and believed these would be listened to and addressed, while workloads were generally described as manageable with support available when needed.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Throughout our assessment there was no evidence that the provider had identified all the concerns we have found through their own internal processes. No evidence care plan audits were conducted to enable the providers to identify inconsistencies that we found within people’s care plans. Policies and procedures were inaccurate and were not embedded. We found accident and incidents analysis did not record all accidents and incidents that occurred in the service. 1 being a fracture to a person's arm following a fall. We reviewed action plans that had not been routinely reviewed and the provider could not be assured that actions had been implemented and embedded. Actions set for staff were not consistently clear. Statutory notifications were not always reported to us. The provider felt some of the issues occurred due to information being stored on old systems.

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. Referrals were not consistently raised where appropriate.

However, we received positive feedback from healthcare professionals regarding the partnership working. A healthcare professional told us, “I have always found Dedicated Care East Anglia to be happy to work alongside myself and other professionals as needed in the best interest of individuals.”

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. The inspection identified several concerns and the service failed to identify these issues, take appropriate action and actively learn lessons. However, when the provider was informed of these concerns, they sought help from a consultant with experience in adult social care, to assess and review the risks we identified, and they have arranged to provide ongoing governance support. The nominated individual has already begun reviewing the accident and incidents records and working with staff around their accuracy of recording and reporting incidents.