Affinity Trust - Domicilary Care Agency - Leeds

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• 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 good. This key question has changed to requires improvement. 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 governance at the service.

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 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 management team and staff shared a vision to provide good care to people to enable them to remain in their own homes and to be as independent as possible. A staff member said, “A massive emphasis is on autonomy and independence and that aligns with my values as well because I think that’s a massive part of my role as we are there to promote independence.”

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, experience and credibility to lead effectively.

While leaders shared a commitment to working to improve standards, this was not always consistent or effective. Frequent changes in management had contributed to instability.Leadership oversight had not consistently identified or addressed the issues we found in a timely and effective way. Records of action plans and service reviews showed the registered manager had left, and periods of managerial change had contributed to gaps in oversight. The provider acknowledged this and stated they were working to strengthen leadership arrangements and improve overall monitoring.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff said they were confident to speak up, could report issues through established processes, and felt listened to. A staff member said, “I would speak up definitely, I think if someone isn’t being looked after I would speak up and report it.”

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. Staff felt they were treated fairly and worked well with the wider team. A staff member said, “We have staff meetings. Its calm, collective, everyone knows what they’re doing and its well organised.” Staff completed training in equality and diversity and understood what it meant. Recruitment and disciplinary processes were in place and ensured there was no disadvantage based on staff's specific protected equality characteristics.

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.

Quality assurance processes were not robust to ensure people’s care consistently mitigated risks to their health, safety and wellbeing. We found shortfalls in several areas, including environmental risk, staff training, care planning, risk management, supervision arrangements and medicines management. Audits had been completed in some areas; however, low scores were repeatedly identified, indicating that the audits were not effective in driving the improvements required. Although the service had an action plan in place, several actions had not been completed since January 2026, meaning issues were not being addressed in a timely manner increasing the risk of them reoccurring. In addition, the provider had not followed their regulatory responsibilities to notify CQC of incidents.

The provider recognised its responsibility to work collaboratively with other professionals so that services operated smoothly for people. We saw examples of appropriate referrals and advice being sought from speech and language therapists, physiotherapists, social workers, GPs and district nurses. However, partnership working was not always effective. The provider did not consistently share information or learning with relevant agencies, nor collaborate fully to support improvement. For instance, we identified incidents that had not been reported to the local safeguarding team or CQC.

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. For example, we identified incidents where actions were not always taken to mitigate future risks.

Even though shortfalls were found during the inspection, the provider was accepting of the feedback provided and took this onboard to learn and improve. They told us an improvement plan would be in place promptly to help address the concerns raised and provide assurance.