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 questionrequires improvement.At thisassessmentthe rating hasremainedrequires improvement.This meant the management and leadership was inconsistent.The serviceremainedin breach of legal regulation in relation togovernance and oversight of the service. AlthoughSystems of oversightwithin the service had improved,given the history of non-compliance at this service, more time was needed to ensure systemsand processeswere embedded and sustainedtosupport 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 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 vision, values, and strategy for the service had been developed but were not widely understood by staff.

More needed to be done to ensure staff were aware of the visions and values of the service and how this related to their role. The provider had updated its statement of purpose, which is a legally required document that explains who a care service is, what it does, and how it does it. This included information about the aims, objectives and strategic direction of the service. The provider told us that work was also planned to develop and improve their website to ensure it aligned with the current service provision and statement of purpose. Although we saw there was an opportunity for staff to discuss the updated ‘statement of purpose’ during their supervision meetings, other opportunities to discuss and embed the service’s strategic direction and visions and values were missed. For example, staff meeting minutes from January and March did not show any discussion on these topics. Staff were still not clear on what the visions and values of the service were or how these related to their role. A staff member said, “There might be (a set of visions and values), but I can’t think of it.” The strategic purpose for key changes such as the change in management structure, had not been communicated effectively to ensure staff were clear about how this impacted their own work. Although we saw a structure chart displayed in the service, a staff member told us, in relation to the new management team, “It doesn’t feel much different. I think they are here to support the manager.”

The provider also told us about plans to introduce key performance indicators to give better oversight of the service’s performance in important areas, including sickness, staff training and safety incidents. These were still in the early stages and had not yet been introduced into practice.

Systems and processes required development to demonstrate the provider had consistently ensured leaders at all levels understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

The service was overseen by a registered manager who understood their responsibilities to deliver good, effective and high-quality care. We saw evidence that support for the registered manager had improved, however, more time was needed to ensure new systems and processes were embedded and sustained to ensure consistent and ongoing support for the management team. The registered manager had attended a supervision meeting in January 2026, which 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, identify learning gaps and agree objectives. Leaders told us these would be taking place every 3 months going forward. There was a new management structure within the organisation, including a compliance support officer and an assistant general manager who had been recruited to improve oversight and governance of the service. The registered manager told us they felt this would provide greater peer support for them. Although there was evidence of early improvement because of the new leadership structure, the role of assistant general manager had only recently been introduced so it was not yet evident how this role would improve the standards of support and supervision across the service.

Staff told us they felt leaders were visible and had the skills required the lead the service well. Comments included “If her [registered manager] door is closed, you know it’s for a meeting. She always has her door open, and you can pop in. She is always there” and “From what I’ve seen, they [leaders] have the right skills.

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, which outlined how staff could raise concerns safely in the workplace. This had recently been updated to include up to date information, so staff were equipped with the necessary details to speak up if they needed to.

Staff told us there was an open culture which allowed people freedom to speak up, and they were confident any concerns would be listened to and acted on. A staff member said, “In staff meetings, we can raise anything. I feel able to speak up. I don’t always wait for the meeting, if I’ve raised anything they have been sorted right away.” Staff meeting minutes and supervision records evidenced they were used as a safe space for staff to share 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 they were treated well at work and felt they were part of an inclusive workplace. One staff member said “Yes (I feel well looked after at work). I am a vegetarian, if we are having party food, they always make sure they order extra for me.” We saw the registered manager had implemented reasonable adjustments for a member of staff to support them to remain competent in their role. This included pursuing training in alternative formats to remove digital barriers and a review of suitable duties.

The provider had supported the wellbeing of its staff by implementing new support and recognition schemes including a monthly health and wellbeing newsletter led by the service’s health and wellbeing champion, which included wellness tips, resources and contacts for staff to stay well at work, an anonymous app-based employee of the month nomination scheme and regular ‘themed’ wellbeing days.

We found improvements had been made to the governance, management, and accountability arrangements. Systems and processes had improved to ensure the provider had clearer responsibilities, roles, systems of accountability and good governance. However, given the history of non-compliance at the service more time was needed to ensure improvements were fully embedded and sustained to consistently manage and deliver good quality, sustainable care, treatment and support.

New roles, systems and processes had been implemented to improve oversight of quality and monitoring of the service since our last inspection. This included the implementation of a new management structure. A compliance and systems officer and assistant general manager had been recruited to help with oversight and quality monitoring. The assistant general manager role was very recent, so we were unable to make a judgement on the impact of this role on the quality of the service. A service specific improvement plan (SIP) had been created to drive improvement across the service and to provide leaders with oversight of issues and outcomes by capturing key issues identified by audits and systems. The frequency and quality of oversight and monitoring site visits and checks had improved. Spot checks were being completed regularly by the registered manager across both bungalows to provide a clearer picture of the day-to-day care people were receiving. A new ‘visit form’ had been designed for completion when leaders were visiting the service to identify issues and drive improvement. This included prompts to check key quality indicators including cleanliness and safety of the environment, staffing levels and resident engagement. Although we saw these were being completed more regularly, the quality of completion was inconsistent. For example, a service visit form from January 2026 was not fully completed or signed by the person completing the visit. An increased number of audits had taken place, including a comprehensive service audit in January 2026 which had been used to create a report on the quality of the service and had identified some areas for improvement. Not all actions identified as part of this audit had resulted in an action being added to the service improvement plan to ensure outcomes could be measured. Systems and processes had also not identified the improvements identified during this inspection in relation to care plans.

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 service was proactive in contacting partners for support when required, and we saw care records such as eating and drinking and continence care plans included personalised information and guidance created in consultation with other services, including, but not limited to SaLT (speech and language therapy) and the community nursing team. The registered manager showed a greater understanding of the support and resources available from partners and had accessed their support. They had recently attended conferences arranged by the local authority and had accessed IPC support resources via their Integrated Care Board (ICB). People were engaged in conversations about developing their community networks, for example client meeting minutes from April included conversations about attending the local church. The service leaders had started to attend regular meetings with its sister services to share information and learning with others to improve the service and outcomes for people.

The provider had improved its focus on continuous learning, innovation and improvement across the organisation and local system. More time was needed to ensure they consistently encouraged creative ways of delivering equality of experience, outcome and quality of life for people which were embedded and sustained.

Improvements had been made to the quality assurance systems and processes, but these were in the early stages, and more time was needed to evidence they had been embedded and sustained to ensure consistent continuous learning, innovation and improvement across the service. There was an increased number of routine audits and spot checks being completed to identify areas for improvement, these fed into the SIP to ensure longer-term oversight of safety and quality of the service with clear and measurable outcomes. Leaders spoke confidently about how the new systems and processes would be used to continually drive improvement. They acknowledged the SIP was a “living document that would evolve over time”. Although The SIP contained many of the issues identified, including those raised in the last CQC inspection, more time was needed to evidence that issues within the service were independently and consistently identified and recorded with responsive action planned and/or taken. Audits fed into the SIP but there were some omissions such as the purchase of a new oven following an environmental audit, and the introduction of senior management analysis for thematic reviews of incidents. Although these had been identified as an action from routine audits, they had not been added to the service improvement plan to evidence they had been identified and resolved.

Staff were encouraged to develop their skills around innovation, for example the service had assigned ‘champion’ roles to staff members in topic areas including end of life and health and wellbeing. This had led to creative improvement ideas being adopted including the creation of the health and wellbeing newsletter for staff and an improved understanding of good end of life care and support. The end-of-life champion told us “I am passionate about it (end of life care). I’ve learned a lot through experience. I get to support and teach others what I know. I’ve helped with creating end of life care plans. We had a general, informal chat. It made it quite easy to talk about what people want, and we had a lot of information to put into the care plans.”