Calverton Supreme Home Care

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

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 has changed to 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 good governance at the service.

This service scored 57 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They understood the challenges and the needs of people and their communities. Staff and leaders demonstrated a positive listening culture that promoted trust and understanding between them and people using the service. People who used the service spoke highly of the management, staff and their support and their openness. The management team supported an open culture and had created a strong team ethos. Staff spoke positively about working at the service and felt well supported in their roles

Not all leaders understood the context in which the provider 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 or experience to lead effectively.

Whilst all managers were compassionate and knowledgeable about people’s needs, there were not always effective systems in place to ensure people received safe care and treatment. Not all managers were fully aware of their responsibilities to meet CQC regulations. For example, lessons learned were not consistently recorded when things went wrong, limiting the application of the Duty of Candour. The management team were committed to delivering a good service; however, gaps in governance and oversight meant the provider was not always able to identify areas for improvement or fully learn from incidents. This meant people could not always be assured that the service was consistently well-led and that lessons were used to drive improvements in care quality. Staff told us, the management team were approachable and good managers. One staff member said, “Management are approachable and always support me. They are good leaders. I think it’s a lovely place to work as we have a good team and always support each other.”

The provider fostered a positive culture where people and staff felt able to speak up and be heard. People and staff told us they could raise concerns without fear of negative consequences. One staff member said, “I would feel comfortable to raise a concern. I feel like they would listen to my concerns even if it was about them, as they are a friendly group. If I had to whistle blow, I would report to CQC, police, local authority and my managers.”

This meant people and staff were supported to speak up, helping to promote transparency, a safe, and open culture.

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 ensured staff were treated fairly and supported. All staff completed equality and diversity training, and recruitment processes included health questionnaire to ensure reasonable adjustments could be explored if required. Staff told us they felt respected and valued, with no concerns about discrimination. One staff member told us, “The staff are friendly and caring. They always go that extra mile and strive to make a difference. After having my second child, the registered manager supported me when I had to change my working hours so that I could also be present for my children, which gave me the perfect work life/home life balance needed.” This meant staff were supported, valued, and treated fairly, contributing to a positive and inclusive workforce.

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.

Systems to audit the quality and safety of the service were not effective in identifying or addressing areas for improvement. Some audits had been undertaken; however, they failed to identify shortfalls in care. For example, the concerns identified during this assessment had not been identified by the management team. There were gaps in oversight of incidents and accidents, and reportable incidents had not always been notified to the CQC. Care plans did not consistently provide staff with clear guidance on how to support people with their health care needs, meaning staff did not always have sufficient information to deliver safe care. Medicine audits were also ineffective; for example, one person had not received their medicine for the whole of January 2026, and this had not been identified. This meant people were at risk of receiving unsafe care due to ineffective governance and oversight systems

The provider was reactive to our findings and had provided some assurance that improvements, including updated templates, would be implemented to ensure information is shared with all relevant health professionals.

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. For example, where medicine incidents had occurred the management team did not always obtain guidance from appropriate health professionals with right training. This meant people could be at risk from not receiving safe care. People were supported to access the community, for example people had care calls in place to support with food shopping.

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.

Systems and processes were not effective in identifying required improvements or supporting the development of the service. As outlined in the “Safe” section of this report, the management team did not analyse accidents or incidents to ensure lessons were learned. This meant issues were not always recognised or addressed in a timely way. However, quality assurance measures, such as surveys, were in place to gather feedback from people and staff, and actions were taken in response to negative comments.