Gain Healthcare 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 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, and the providers responsibility to notify CQC of incidents.

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 clear shared vision, strategy or culture that was based on transparency, equity, equality, human rights, diversity and inclusion, or meaningful engagement. They did not always demonstrate an understanding of the challenges people faced or the needs of the communities they supported.

The registered manager told us weekly key worker meetings and weekly house meetings were held to support staff communication and engagement. We requested documentation to evidence these meetings. Only one house meeting record was provided, and staff we spoke with told us that these meetings did not routinely take place. This demonstrated a lack of effective communication systems and a failure to meaningfully engage with staff or embed a consistent leadership presence.

Leaders did not consistently understand the context in which the provider delivered care, treatment and support. They did not consistently embody the values or culture of the organisation, and did not always demonstrate the skills, knowledge, experience or credibility required to lead the service effectively. Leadership was not consistently open or transparent, which undermined confidence in the provider’s governance arrangements.

There were inconsistencies between what leaders told us about staff induction and support, and what was delivered in practice. The registered manager told us new staff received two days shadowing period as part of their induction. The provider’s induction policy stated new staff must undertake a structured induction lasting between three and six weeks, supported by a designated buddy, and be signed off as competent before working independently. Staff we spoke with told us they had not received a structured induction and were asked to work with minimal training or support in place. This contradicted both the provider’s stated approach and their written policy.

Staff told us they did not always feel confident raising concerns. Some staff described uncertainty about how to escalate issues and said they were not always able to contact a senior member of staff when they required support. Staff reported that concerns were sometimes passed between different managers without resolution. This indicated a lack of clear leadership structure, poor communication pathways and ineffective escalation processes.

These failings demonstrated that leadership arrangements were unclear, inconsistent and ineffective. Leaders did not provide clear direction, accurate information or a culture where staff felt supported to raise concerns.

The provider failed to foster a culture where people and staff felt able to speak up or confident that their views would be listened to and acted upon. There was an absence of openness, transparency and meaningful engagement, which undermined trust in leadership and governance arrangements.

Leaders were unable to evidence effective feedback mechanisms, whistleblowing systems, or consistent supervision and staff did not feel confident to speak up.

Staff we spoke with told us they did not feel able to speak up. They said concerns they raised were not always addressed and that they did not feel listened to. Staff also told us they had not received supervision and were not regularly checked on by management. Where staff had raised concerns in supervision, we did not always see action taken to support the member of staff. This demonstrated a lack of effective leadership engagement, poor staff support and an absence of a learning or improvement focused culture.

The service’s whistleblowing policy stated that staff had access to a Freedom to Speak Up Guardian. However, the policy did not include any name or contact details. When we asked the registered manager who fulfilled this role, they confirmed that no Freedom to Speak Up Guardian was in place. This meant staff were not provided with a safe, independent route to raise concerns and the whistleblowing policy was not reflective of practice.

The registered manager told us that feedback from staff was sought through staff surveys and supervisions were carried out every four months. However, when we requested evidence of staff feedback, none was provided. We also requested supervision records for specific members of staff, but documentation was not made available. This meant the provider could not demonstrate that staff were routinely supported, listened to or given opportunities to raise concerns or reflect on their practice.

The provider failed to demonstrate that they valued diversity within their workforce or promoted an inclusive, fair and equitable culture for staff. They did not consistently take action to improve equality or ensure staff were treated with dignity, fairness or respect. These failures negatively impacted staff wellbeing and the provider’s ability to deliver safe and high‑quality care.

Staff told us they had not been issued with contracts of employment. Without contracts, staff lacked clarity about their terms and conditions, roles, responsibilities and rights. This significantly reduced assurance that staff were supported appropriately and treated fairly within their employment.

Staff told us they were not always paid correctly, did not routinely receive rotas in advance, and did not have access to effective training to carry out their roles.

The provider was unable to demonstrate systems were in place to ensure staff were scheduled safely or supported with appropriate training and development. These failings disproportionately affected staff confidence, job security and inclusion, particularly for staff who may already experience disadvantage or inequality in the workplace.

The provider did not have effective systems of accountability, governance or oversight in place. Roles and responsibilities were unclear, and leaders did not act on reliable information relating to risk, performance or outcomes. As a result, leaders lacked the assurance required to identify, escalate or address serious and ongoing failings within the service.

The provider described several oversight processes, including daily calls with staff and daily audits. Although audits were recorded within a governance system, audits were ineffective as they did not identify the concerns we had found during inspection.

Audits had failed to identify widespread medicines management concerns. For example, previous audits had identified medicines were being administered, with clear actions for improvement, however, recent, daily record audits failed to identify that staff were still administering medicines without appropriate documentation. Several audits contained incomplete sections, further undermining their reliability. The provider told us that an external company also completed audits and quality checks. However, no supporting evidence was provided for the person we reviewed. Actions such as ensuring medication entries were clear, improving daily notes, and expanding emotional wellbeing entries were identified, however, there was no evidence these actions had been completed. Therefore, governance systems were not effective.

Incident records demonstrated ineffective governance. Incident logs were incomplete, meaning themes and trends were not identified or analysed to reduce risk of recurrence. Audits referred to matters that were not reflective of the notes they had reviewed.

We were not always notified of safeguarding events, which limited external oversight and raised concerns about the provider’s governance arrangements and awareness of their regulatory responsibilities.

The provider told us that weekly senior leadership meetings were held to oversee governance and service improvement. Meeting records included actions relating to medicines and daily documentation, however, did not identify which people or staff these actions applied to, meaning accountability was unclear and progress could not be monitored.

The provider reported that regular spot checks, including unannounced checks, were carried out for staff performance. While we saw evidence of some spot checks taking place, governance control was poor as the policy document contained staff members’ personal information rather than a blank template,

The provider told us that care plans were reviewed monthly. However, no care plan audits were provided to evidence this, and the persons care plan reviewed has not been updated in 3 months.

Leaders failed to ensure governance systems were embedded, effective or used to drive improvement. Risks were not identified or mitigated, learning was not embedded, and accountability was unclear. These were widespread, longstanding and systemic failings, which placed people at ongoing risk of unsafe care.

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.

The registered manager told us the service had received positive feedback from professionals, however, professionals we spoke with raised concerns about the providers governance systems and communications.

Where professionals had carried out comprehensive clinical assessments, this information was not always incorporated into the person’s care and support plan. This meant that important recommendations, including strategies to support the person’s regulation and sensory needs, were not available to staff. As a result, staff did not always have the information required to deliver consistent, coordinated care.

The provider did not always focus on continuous learning, improvement or innovation across the organisation or local system. They did not consistently promote safe, effective or evidence‑based practice, and opportunities to learn from incidents were routinely missed.

We were told that incidents and accidents were analysed and reviewed, with lessons learned documented. However, we did not receive evidence of this. This meant the provider could not demonstrate that learning had been identified, shared with staff or used to improve practice.

Incidents recorded within daily notes did not contain enough information, and where the provider was made aware of further concerns, had not been updated or investigated to ensure appropriate action or learning took place. Without accurate records, the service was unable to implement effective learning or take appropriate action to prevent similar incidents from happening again.

Daily note audits identified where strategies needed to be implemented to support the person, however, there were no actions arising from this. Staff therefore did not have the learning or guidance they needed to apply support strategies consistently or effectively.

Audits identified that refresher training and record keeping accuracy was recommended, however, the training matrix did not include this training, demonstrating a failure to follow through on identified learning. Action plans lacked detail, follow through and accountability.