Xcel Homes 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.

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.

The service was in breach of legal regulation in relation to governance.

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 provider’s statement of purpose reflected the service’s vision and values. Staff were clear about the provider’s expectation of them and demonstrated the provider’s values in their day‑to‑day practice. A staff member said, “The service’s aim is to promote people’s independence and support people to live their own life as independently as possible, maintaining safety and dignity.”

The management team had developed a positive culture of inclusiveness, openness and transparency. People and relatives were consistently positive about the quality of care provided and how well the service was managed.

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. However, this inspection identified some shortfalls in the registered manager’s oversight, systems and processes. The registered manager acknowledged they needed to strengthen their management procedures and showed a commitment to make improvements.

The registered manager had not fulfilled their registration regulatory responsibilities of reporting notifiable incidents as required. The registered manager acknowledged this was an error and assured us of the actions they would take to further upskill their knowledge and improve their systems and processes.

The management team had recently expanded, with the recruitment of an experienced care coordinator. The management team were in the process of developing roles, responsibilities to increase accountability to further develop the service.

The registered manager was open and honest during the assessment and took some immediate actions to the shortfalls identified during this inspection.

Staff confirmed they felt the management team were supportive and good leaders, they felt valued, respected and listened to. A staff member said, “The manager is very approachable, knowledgeable and supportive. He's a physiotherapist by profession and is very clear about do's and don'ts, we do things by the book, they tell us straight.”

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

The provider had systems and processes, including policies and procedures such as Freedom to Speak Up, Whistleblowing and Safeguarding to support staff to raise any concerns.

Staff were positive about working for the provider. A staff member said, “We have a strong positive staff culture. The manager is very approachable, they listen and encourages us to raise any issues concerns, worries and to speak up. “

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 received equality and diversity training, equipping them with the knowledge and awareness to recognise and respect people’s individual characteristics, cultural backgrounds, and personal identities.

Staff were positive about the support they received in their role. A staff member said, “The manager highly respects the staff who work with pride, they always welcome new staff and are respectful and provide very good guidance. I think it's a good company to for work for. The manager is very supportive and approachable.”

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 provider’s governance systems, processes and procedures that assessed risks, and monitored quality and safety were not fully effective. They had failed to identify the shortfalls we found during this inspection.

The failure to have procedures in place to effectively review and monitor the service, meant that the ability to identify trends, patterns and themes to support learning, development and improvement was limited.

The provider’s internal audits and checks were not sufficiently robust. They had failed to identify the shortfalls in risk management and mitigation, inconsistent and or missing information in care plan guidance for staff and had not recognised the gaps in best practice guidance.

The management team had overstretched themselves in working in the field, this had a negative impact on oversight and management responsibilities not being fulfilled. The registered manager in discussion with us, recognised this and was making immediate improvements to address these issues.

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 registered manager told us, and records confirmed, there was a positive approach to partnership and collaborative ways of working. Referrals to external professionals were made in a timely manner, and guidance and support were sought when required from external health and social care partners.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The shortfalls in systems and processes reported in the Key Question Safe and Well-led demonstrated how improvements are required in leaning, improvement and innovation.

The provider shared an improvement plan. This was largely based on the feedback received from this inspection. Whilst this showed a commitment to make service delivery and development improvements, it also confirmed how the provider’s internal systems and processes were not fully effective in identifying areas for improvement.

The registered manager acknowledged they had limited external contacts to offer guidance and support but told us they would review how this could be improved upon.