Open Doors Healthcare Services Ltd

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 changed to 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.

The registered manager led a positive culture. Staff told us they had regular meetings with the registered manager who shared their vision and instilled a passion in their role in people’s lives. The registered manager worked closely with care staff to make sure they understood their values and expectations.
A person told us, “From the beginning they have done what they said they would do. I would recommend them.”
All staff we spoke with told us their induction into the service was with the registered manager. A member of staff said, “My induction was very detailed. I shadowed for 1 to 2 weeks with the registered manager. I learnt a lot as they told me what they expected of me, and I was able to ask questions. The registered manager is still always available.”
 

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 had only positive feedback about the management team, from people, relatives and staff. Their commitment to providing good quality care was evident during the inspection site visit and confirmed by the feedback we received.
Staff told us they felt supported by the management team and could raise any concerns. A member of staff said, “(The registered manager) standards are clear and followed through.”
A relative said, “You cannot get a better company, even better than the one I worked for.”
 

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

Staff told us they had opportunities to raise concerns with the registered manager during regular one to one meetings and staff meetings. However, they also said they would have no hesitation making contact with the registered manager at any time if they had a concern. All the staff we spoke with said they were confident the registered manager would listen to them and take action.
People and relatives knew the registered manager and said they felt comfortable raising issues with them. A person said, “I do know the manager and I feel confident to make a complaint”. A relative commented, “I do know the manager and my dad does too. I know where to go to complain.”
 

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 had an equality and diversity policy, which was followed by the management team.

Staff told us they had felt included in the staff team when they joined, the registered manager made them feel welcome and took into consideration their personal life.

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.
Although the registered manager managed and delivered good quality care, treatment and support which was evident by the feedback we received, their governance system required some improvements to ensure sustainability. There were processes in place to monitor the quality of the service, however, these had not been effective in identifying the shortfalls in recruitment practice. The shortfall had not impacted on people’s care as the registered manager was fully involved in all aspects of care and worked closely with staff. The systems and processes in place to monitor quality and safety were sufficient due to the small number of people receiving care and support and the undivided attention of the registered manager. However, the registered manager accepted the current systems and processes may not be enough to sustain continuous improvement if the service increased in size.
Following our onsite assessment, the registered manager sent assurances of the immediate action they had taken to meet the requirement of safe recruitment, with an action plan setting out how they would sustain the improvements. The registered manager also shared their plans to change their governance systems to build in extra sustainability for the future.
 

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.

Where relevant, staff referred people to the appropriate healthcare professionals if their needs changed or they had concerns about their health or medical conditions.

The management team attended local meetings and conferences to share information and best practice with partners and other agencies. They were involved in local relevant social media groups to keep in touch and seek support when necessary.
 

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 registered manager was keen to learn from incidents and experiences and to share this with staff. Staff told us they had regular meetings where they were encouraged to share experiences and reflect on their practice to benefit all staff. Communications were sent to staff though the electronic recording system or encrypted group chats when people’s care changed as a result of learning through experience, to improve people’s quality of life. A member of staff shared, “(The registered manager) communication is excellent and she always includes all staff.” Another staff member said, “To learn lessons we do a reflection, what went well and what didn’t go well and this is shared.”

The registered manager told us they had signed up to be part of a university research programme in relation to homecare.