Enliven Social Care 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 service 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 newly registered service. This key question has been rated 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.

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 or strategy. They understood the challenges and the needs of people and their communities. However, systems and processes did not always support effective oversight and risk management to ensure people always received safe care.

Some improvements were required on maintaining accurate records and learning from audits. Further time was required to ensure these processes were fully embedded and sustained.

The culture at the service was person centred. People and staff spoke positively about the provider. Staff liked working at the service.

The provider told us they were focused on learning and making improvements within the service.

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.

However, leaders did not always have effective oversight of care delivery, treatment and support. For example, whilst quality assurance processes were in place these were not always effective because there was not always a record of actions taken. The registered manager said, “We do the checks however, we don’t always record what we have done, and we need to record what we have done.” The shortfalls we identified during our assessment as detailed throughout the report had not always been identified in their quality assurance processes.

We found where safeguarding concerns had been identified action had been taken to mitigate the risk and a referral had been made to the funding authority. However, the provider had failed to notify us. Whilst no harm had come to the person. The provider is required to notify us of any safeguarding incidents these incidents in question did not fall within the remit of CQC. The registered manager recognised this was an oversight and they should inform us of any safeguarding incidents going forward.

People told us they could contact ‘the office’ and any issues or concerns were quickly responded to.

Staff told us the registered manager was approachable, supportive and available when they needed advice or had concerns. A staff member told us, “This is the best place for me to work, they really want what is best for people.”

Systems were in place to guide staff on what was expected of them through staff meetings, observed practice and one to one meetings.

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

Staff felt comfortable raising issues and that concerns would be addressed. Whistleblowing and speaking up were discussed in team meetings.

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.

There were procedures in place to consider staffs’ individual needs and to ensure all staff were treated equitably.

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, or share this securely with others when appropriate.

The registered manager did not always have effective oversight of audits in place. They had failed to identify the shortfalls we found during this inspection.

Systems and processes were in place but required improvement. Whilst the provider was completing audits of their electronic care management systems (ECM), these were not robust and had failed to identify themes and trends. For example, we reviewed the providers call logs over a 3 month period. The providers audits had failed to identify where adequate travel time had not been given, where 2 staff were logged into 2 calls simultaneously and almost a quarter of the calls were manually logged. While the majority of people told us staff attended calls at the correct time and stayed for the correct amount of time, managers could not be assured because systems and records could not evidence this was the case.

The Medication audit completed by the registered manager, failed to identify that systems could not evidence if time critical medications were consistently administered at the correct time. This limited the providers ability to identify pattern, themes, or repeated concerns, such as whether the same staff members were involved.

Whilst complaints had been reviewed there was missed opportunities of learning and preventing the risk of occurring again. For example, although staff had made appropriate changes in response to a complaint, the care plan had not been updated. This meant there was a risk staff would repeat the identified concern. We were not always assured complaints were investigated without delay and in line with the providers policy.

Where people had falls, the audits in place had not identified the missing information about the injury as described in the Safe key question.

The registered manager assured us following feedback from the inspection that they had reviewed their audits and would be making these more robust to identify themes and trends.

The provider had a business continuity plan in place, in case of emergency or natural disasters, such as adverse weather events or loss of staff. A red, amber, green, (RAG) rating was also used to identify vulnerability when unforeseen circumstances affected the service. This would enable the provider to prioritise people’s needs.

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.

Professionals involved with the service told us the provider worked in partnership with them. The provider had linked into further training available to staff through the local authority.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

There was a lack of systems to ensure continuous learning. The provider’s own quality assurance was not always effective and had failed to identify the shortfalls found at this inspection. Audits completed did not always reflect required improvements or always support a learning approach.

The manager welcomed our feedback and had started to take action to address the issues identified during our inspection.