Anytime Care 2020(Leicester)

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 62 (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.

Staff were clear about the provider's expectations of them and demonstrated the provider's values through their day-to-day practice. Staff spoke positively about the importance of delivering person-centred care and promoting people's dignity, independence, choice, and wellbeing.

Staff meeting records also showed how the registered manager regularly communicated the provider's vision, values, and expected standards of practice. Discussions included promoting respectful and inclusive care, learning from incidents, sharing good practice, and ensuring people remained at the centre of care delivery. This helped staff understand their roles and responsibilities and supported a positive culture focused on achieving good outcomes for people.

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.

The registered manager was passionate about leading the service and was committed to achieving positive outcomes for people. They demonstrated a good understanding of the people using the service, the challenges faced by the service, and the importance of maintaining a person-centred culture.

The registered manager encouraged open communication and actively sought feedback from people, relatives, and staff to help drive improvements. Staff told us they felt able to raise concerns, seek advice, and discuss issues with the management team. This helped to promote an open and inclusive culture where people and staff felt listened to and supported.

The registered manager supported the inspection process and engaged openly and transparently throughout. They were receptive to feedback and where shortfalls were identified, the registered manager responded positively, acknowledged the concerns raised, and showed a clear commitment to taking action to address them

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 confirmed they had access to the provider’s policies and procedures and felt confident of speaking up when required.

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 systems and processes, including policies and procedures such as freedom to speak up, whistleblowing and safeguarding to support staff to raise any concerns.

Staff felt confident speaking up when required. They told us they found the registered manager to be supportive and approachable, and they had regular contact with them. A staff member said, “The registered manager is approachable, provides clear guidance, encourages teamwork, and promotes high standards of care and professionalism.”

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.

The registered manager described a programme of daily, weekly, and monthly audits and quality assurance checks. This included undertaking a comprehensive 'mock inspection' approximately 3 to 4 times per year to review compliance and identify areas for improvement. However, the registered manager told us these had not been maintained during the previous 24 months and provided an explanation for this shortfall.

We reviewed an example of a ‘mock inspection’ completed in 2025, which identified areas for improvement and resulted in an action plan. A follow-up review completed in early 2026 confirmed that the identified actions had been addressed. However, this inspection found improvements had not been fully embedded and sustained.

It was not always clear how information gathered through the provider's monitoring activities were being used to identify themes, trends, and areas requiring improvement. Whilst the provider had a learning culture, this was limited and not fully effective. This was reflected in the shortfalls identified during our inspection.

The provider’s systems and processes had failed to sufficiently assess and mitigate known risks of people’s individual care needs as reported in the Safe and Effective key questions of this report. These shortfalls meant people were at increased risk of receiving unsafe and inconsistent care impacting their health, safety and wellbeing.

The provider’s monitoring procedures of staff training requirements were ineffective. They had failed to ensure staff had the right skills, knowledge and competency to safely meet people’s individual known care needs. This put people at increased risk of receiving unsafe care and treatment.

The provider’s systems and processes of monitoring medicines management procedures were not sufficiently robust. The provider had failed to follow their own medicines policy and national best practice guidance. This meant people’s health, safety and wellbeing was put at potential risk.

The provider’s audits and checks of staff recruitment records were not robust. They had failed to ensure that all required recruitment procedures had been completed and that records were maintained effectively, in order to provide assurance that safe recruitment practices were being consistently followed and appropriately monitored.

The provider’s systems and processes for reviewing and monitoring people’s care plans were not fully effective. They had failed to ensure care plans were accurate, up to date, and reflective of people’s current care and treatment needs. Inconsistencies within care plan documentation and guidance for staff increased the risk of people receiving unsafe or inappropriate care and treatment.

The provider had failed, through their monitoring systems and processes, to identify that the legal requirements of the Mental Capacity Act 2005 were not being met and that their own MCA policy was not being followed. This meant the provider could not be assured that decisions were being made lawfully and in people’s best interests, placing people at risk of receiving care and treatment that did not fully respect their rights, choices, and legal protections.

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, staff worked collaboratively with external health and social care professionals. This collaborative approach supported people’s health, safety and wellbeing.

Information was shared appropriately and staff sought advice and guidance from partner organisations when concerns arose or additional support was needed. This helped to ensure care was coordinated, responsive and focused on achieving the best possible outcomes for people.

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

Opportunities for learning and improvement had not always been effectively identified through the provider's governance and quality assurance processes. As identified during this inspection, auditing and oversight systems had failed to recognise a number of shortfalls identified during this inspection.

We found the registered manager was committed to learning from inspection feedback and enhancing the quality and safety of the service.

The registered manager told us of service developments and improvements that had been made. This included how they were currently in the process of transitioning to a new electronic monitoring system, which they believed would provide greater oversight and monitoring of service delivery.

The registered manager told us they were committed to continuous improvement and used CQC guidance and national best practice to support service development.