Quality Care

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 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 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 culture and ensured staff in all areas understood the values of the service and how their role helps in achieving them. The provider and staff worked collaboratively with relevant healthcare services to ensure delivery of care. A clear management structure was in place. The care manager told us, “We encourage staff to share their experiences, ideas and suggestions for improving the service and to share good practice with one another. We believe that maintaining an open and supportive relationship with staff helps create a culture where people feel confident to speak up and contribute to improving the quality of the service.”

Staff had clear roles and responsibilities and were informed of their roles and reporting arrangements. Staff spoke positively about the management of the service. A staff member told us, “I have an understanding of my role and responsibilities, and the organisation helps to make things clear.” Another staff member told us, “I enjoy the positive attitude towards people and continuity of care provided by the [registered manager].”

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 service was managed by the registered manager and a care manager.

People and relatives were complimentary about the leadership approach of the registered manager who they consistently described as approachable, responsive and reliable. A relative told us, “It gives me great peace of mind that I can continue to work knowing [person] is well cared for. I can be their [relative] and visit instead of feeling I have to do the hands on. I am delighted with [person’s] care.”

Staff spoke positively about the management of the service. They said they were well supported and felt like a valued part of the team. A staff member told us, “Managers are approachable and provide support when required.” Another staff member told us, “I feel comfortable contacting the office and raising concerns.”

The provider fostered a positive culture where staff felt they could speak-up and their voice would be heard. Staff told us they knew how to speak-up if they had concerns or something went wrong. They felt the provider supported them and listened to them.

Staff were able to discuss issues at supervision meetings and team meetings. A staff member told us, “I find the service flexible and responsive to concerns that I raise.”

The care manager told us, “We encourage all staff to speak up and feel comfortable raising any concerns, suggestions or ideas they may have about the service. We have an open-door approach, and staff can speak directly with the care coordinator, myself or the registered manager at any time.”

People and relatives were able to approach staff and the registered manager if they had any concerns. A relative told us, “The manager is very good and supports me and shares information about the carers and their procedures. I have the managers phone number. Another relative told us, “The service is good and the manager is very good and keeps me updated.”

The provider valued diversity in their workforce. Management and staff worked together as a team. Policies and procedures were in place for workforce equality, diversity and inclusion to enable a more equitable and inclusive organisation.

The care manager told us they took active steps to ensure equality, diversity, and inclusion was promoted for staff in areas such as induction, training and monthly team meetings to ensure staff understood the importance of treating everyone fairly, respectfully, and without discrimination. Staff told us they felt supported and understood what equality and diversity meant and importance of treating people equally and fairly.

The provider had responsibilities, roles, systems of accountability and governance systems in place. Audits and checks were completed to assess and monitor the quality of the service covering areas such as record keeping, medicines, health and safety and infection control. Where issues were identified, action was taken to improve on the quality of the service where needed.

However, during this assessment, we found significant shortfalls in relation to recruitment. Recruitment processes were not robust to ensure safe recruitment of staff. There was a lack of oversight and shortfalls in governance as staff records had not been audited to ensure pre employment checks had been undertaken effectively.

We raised these issues with the registered manager and care manager who were receptive to the feedback and sent us an action plan outlining the actions they would be taking to address these issues and strengthen their recruitment processes. The care manager told us, “We are committed to ensuring that these actions are implemented immediately and embedded into our normal recruitment and quality assurance processes.” We will follow up these actions at the next assessment.

During this assessment, we found the registered manager and care manager to be open and transparent. They were receptive to feedback and cooperated with the assessment process and demonstrated a wiliness and commitment to learn from feedback and promote best practice.

The provider understood their duty to collaborate, work in partnership and share information and learning with partners and collaborate for improvement. The provider worked with other professionals if needed to help make sure people received continuity in their care. A healthcare professional told us they would be confident in using the service again and feedback from people and relatives has been positive. The service had informed them when there was a change in people’s needs and communicated well with them. The healthcare professional also told us they felt people were treated with kindness and received person centred care and support.

The provider focused on learning and improvement across the organisation and local system. Processes were in place to ensure learning was reflected and good practice identified from daily notes, information sharing with staff during team meetings and audits which monitored the quality of service being delivered. People, relatives and staff were encouraged for their views about the service and what could be improved. The service worked with healthcare professionals that supported learning and good practice to deliver effective joined up care.