Mushavi Private Limited

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service. This key question has been rated 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 64 (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 and staff shared a commitment to provide person-centred care. The culture of the service was open and inclusive, and people received good outcomes. Staff enjoyed their work. They spoke warmly about the people they supported and of their team. Staff confirmed they felt valued for the work they did.

Leaders understood the context in which the provider delivered care, treatment and support. They embodied the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

The registered manager was an experienced registered nurse with a clear understanding of how to deliver safe, high-quality care. However, they were still developing their knowledge of regulatory requirements. To strengthen this, they had begun undertaking a care management qualification, were liaising with another provider, and attending a local care network group. Where areas for improvement were identified during the inspection, they responded promptly and took appropriate action.

Staff, people and relatives were complimentary about the registered manager and told us they led the service effectively.

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

Policies and procedures were in place in relation to whistleblowing. The registered manager told us they encouraged staff to raise any concerns with them. Staff confirmed this and demonstrated they understood when to raise concerns.

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 policies in place to promote equality and diversity. Staff received training in equality and diversity and told us they and people were treated fairly. The registered manager told us of an example where they adapted a staff member’s work due to their religious beliefs.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance.

Some governance systems were in place. These included spot checks, quality audits and reviews of feedback from people and stakeholders. However, further development of the provider’s audit processes was required to ensure all areas of the service were effectively monitored. The service was small and the registered manager had oversight. This reduced the risk of poor care. However, the development of the governance system will assist the registered manager in monitoring the service, particularly if the service expands. The registered manager told us of their plans to employ an office staff member and to strengthen their quality assurance systems.

Staff understood their roles and told us they had confidence in the registered manager.

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 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. They did not always actively contribute to safe, effective practice and research.

Whilst a range of audits were undertaken, these required further development and to become fully embedded to consistently bring about improvement.The provider did not have an action plan but told us they would implement this to support learning and improvement.

Staff learnt from incidents and actively sought support from the registered manager and external professionals to implement positive changes in care delivery, resulting in positive outcomes for people.

The registered manager was extremely responsive to feedback given during the inspection and took immediate action to address any concerns or shortfalls within the service.