Essex Care Consortium - Marks Tey

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 requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to governance and oversight of the service.

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 did not have a clear shared vision and strategy to ensure staff in all areas knew, understood and supported the strategic goals of the service and how their role helped in achieving them. The provider and registered manager had not ensured the vision, values, and strategy for the service had been developed through a structured planning process in collaboration and co-production with people who used the service, their representatives and staff, which focused on enabling people to enjoy their lives. Although staff told us that there was a positive and open culture, they were not clear about what the service aims and objectives were. Staff responses were not consistent and did not align with information from other sources such as the company website and the service’s most up to date statement of purpose. Staff meeting minutes, and staff supervision did not demonstrate discussions around the service’s vision and values were regularly discussed which meant that they were not widely understood by staff. However, staff told us morale had improved and spoke of a culture of working together as a team, supporting each other and the registered manager to make improvements. This included more consistent staff, more training, and the implementation of procedures not previously in place, which had had a positive impact on the service.

The provider had not always ensured managers had the skills, knowledge, experience and credibility to lead effectively. The registered manager did not always receive the support they needed from the provider to ensure they fully understood their responsibilities to deliver good, effective and high-quality care. The nominated individual, representative of the provider, was failing to provide sufficient support to the registered manager through regular systems of supervision and appraisal that provided them with the opportunity to discuss their day-to-day work, any concerns they may have, identify any support needed in their working practice, promote their professional development, and identify learning gaps and agree objectives. Their last recorded supervision was dated 14 March 2023. This was carried out by a previous general manager no longer employed at the service. Further work was needed to ensure the nominated individual and registered manager kept up to date with best practice guidance, and changes in legislation to ensure they understood the requirements and recommendations made by CQC, including the ‘fundamental standards’ of safety and quality that all registered providers must meet.

The registered manager was visible and available to provide support to staff, and staff told us, demonstrated a positive and compassionate attitude which had promoted trust and understanding between them, and the people using the service to build a culture that focused on enabling people to enjoy a full life. Staff comments included, “The manager has done an amazing job here. 100% improvement. Morale is so much better, we have a happy workforce, work as a team, like a family. Colleagues know if you are having a bad day at work or personal and provide support,” and “We are equipped with the tools to do our job. Improvements made have been phenomenal, but we are aware there is still more to do.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The service had a freedom to speak up policy, however, this needed updating to reflect the change in director and nominated individual. Without the correct information regarding who to contact would make it more difficult for people to speak up if they needed to. Staff told us that they felt able to speak up and that they were confident that their concerns would be listened to and acted on. Staff had received ‘freedom to speak up’ training and could explain what this term meant. A staff member said, “I am aware of the term ‘freedom to speak up.’ To me, it means being able to raise concerns, share ideas, or report problems without fear of blame or negative consequences. Managers encourage us to speak up by being approachable, listening carefully, and taking concerns seriously. I have spoken up before about a small issue with equipment, and the managers listened, acted quickly, and made sure the problem was resolved safely. This makes me feel confident to raise concerns whenever needed”. Staff meeting minutes and supervision records showed these were used as a space for staff to raise concerns if they needed to.

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 employed a multi-cultural and diverse workforce and had an equality, diversity, and inclusion policy in place to ensure that staff were treated fairly in the workplace. Staff told us the service was a good place to work, and they felt supported by their colleagues and managers. One staff member said, “I am treated well at work. It is a good place to work, and the team is supportive and respectful. We communicate well, help each other, and work together to give good care. Morale is positive because staff feel listened to and valued. When problems come up, we talk about them and solve them as a team”.

Staff meetings and supervisions were held regularly and were used as an opportunity to discuss work related stress and wellbeing and gave all staff equal opportunities to discuss career progression. For example, we saw that a member of staff had been supported to begin a qualification and to take on more responsibility as a shift leader following their supervision meeting. The nominated individual told us that they valued their staff and understood the importance of staff retention and was considering providing private health insurance for all staff.

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. Systems and processes to assess, monitor and improve the quality and safety of the service were not used consistently to identify and drive improvement. There was a lack of clear and effective governance, management, and accountability arrangements in place. Oversight of the service was lacking, resulting in improvements not always being identified and made. The provider was not following their own governance policy, to ensure effective governance. Although a range of audits were being completed by the registered manager, these had not picked up on issues we found on inspection in relation to fire safety, environment, infection prevention and control and recruitment checks. For example, environmental audits, failed to identify remedial works needed to address the poor condition of bathrooms and showers and the risk to people using these facilities.

Where issues for improvement had been identified in the environmental audit, there was no action plan with timescales for completion. For example, checks had been completed on water temperatures to minimise the risk of burns and scalds, but where temperatures had exceeded the expected range in February, April and May 2025, there was no information about the date these had been resolved. Although the maintenance team and registered manager explained that these were prioritised and rectified immediately, the records did not evidence this. Environmental audits included a section for sign off by the nominated individual, but these were not being signed and dated to confirm they had been checked and any issues resolved.

The Quality Assurance Analysis Report Essex Care Consortium Ltd completed in July 2025, stated, ‘Quality assurance supports continuous improvement through regular audits, monitoring, incident reviews, staff supervision, client feedback, and service evaluations.’ The nominated individual was unable to demonstrate the implementation of these principles of auditing and how the results of audits informed the quality monitoring and improvement cycle.

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 that the service is proactive in contacting them for support when required, and we saw care records such as health and eating and drinking care plans included personalised information and guidance created in consultation with other services, including, but not limited to SaLT, community nursing team and the hospice. Comments from professionals included, “I have had no concerns with any delays in care,” and “Manager appeared to know the patients and understood the risks to their health and well-being”.

Although the registered manager told us that they worked closely with the registered manager of Essex Care Consortium Marks Tey’s sister services, they were not currently attending any external forums to share and learn best practice across the sector to improve outcomes for people.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. Our assessment found improvements were still needed to ensure continuous learning, innovation and improvement across the service. Our previous inspection in 2023 identified the provider had no overarching service improvement plan (SIP) to review the longer-term oversight of safety and quality of the service to ensure improvements were identified, made and sustained. At this inspection the nominated individual provided a SIP dated May 2025; however, this was not service specific to Essex Care Consortium - Marks Tey. The registered manager had developed an improvement plan, but this had not been agreed, signed off or monitored by the nominated individual, as representative of the provider.

The nominated individual or registered manager could not demonstrate they had a good understanding of effective quality assurance. Without robust processes in place there was no assurance that improvements would be made, embedded or sustained. Systems to analyse information, were still not being used effectively to see what information was telling them, identify the strengths and weaknesses of the service and where improvements were needed. Trends, themes or root causes of incidents were still not being looked at rigorously to understand why something happened and put robust measures in place to prevent reoccurrence. The nominated individual acknowledged these areas of concern and told us how they intended to make the improvements needed, including recruiting a compliance manager and assistant general manager to provide greater oversight and support in this area.