Chapel And District Bespoke 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 inspection for Chapel and District Bespoke Care Ltd since they registered with CQC. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
 

This service scored 68 (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.

People and relatives told us they would recommend the service to other people in similar circumstances and had done so. One relative said, “No hesitation about recommending to others, I couldn’t recommend them highly enough”.

Feedback that we received from staff showed that the provider strove to maintain a fair, open and inclusive culture. Staff described a supportive culture where teamwork was promoted. Staff received information on the requirements of their role, including the policies and procedures in place and the systems used to meet people’s needs, through training, spot checks and supervisions.
 

The provider had inclusive leaders 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 had the experience, capability, and integrity to ensure the homecare service met people’s needs. The registered manager was knowledgeable about issues and priorities essential to ensure the quality of services and was alert to any examples of poor culture that may affect the quality of people’s care.

Where we had raised concerns following our visit to the office; gaps in some records and in relation to the address of the office needing to be registered. The registered manager immediately put plans in place to address those areas identified and offered assurances these would be completed, sending updates to us to evidence their compliance. After our visit we continued to receive updated documents and confirmation that the new location registration had been submitted to CQC.
 

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

When concerns were raised, the registered manager investigated sensitively and confidentially. The registered manager told us that when something goes wrong, people received a sincere and timely apology, and were told about any actions being taken, to prevent the same happening again.

The registered manager encouraged staff to raise concerns and promoted the value of doing so. However, not all staff felt confident that action would be taken should they share their concerns.
 

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 policies and procedures for inclusion and diversity within the workforce. For example, recognising people’s protected characteristics and ensuring appropriate measures were in place to support these. Protected characteristics are a set of nine characteristics that are protected by law to prevent discrimination. For example, discrimination based on age, disability, race, religion or belief, and sexuality.
 

The provider had clear responsibilities and roles of accountability. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Although systems were in place to assess, monitor and improve the quality and safety of the service, further improvements were needed.

Audits had not identified some of the shortfalls found at this inspection and required further development. This included the need to ensure risk assessments contained full information and a risk score level, so that people were assessed fully. No harm was identified as a result, but the lack of oversight meant some information about people was not up to date or fully completed. For example, a recent audit of care plans had not picked up the areas we found were incomplete. These were acknowledged on our inspection, corrected and evidence submitted to provide assurances that going forward, these would be addressed and captured. However, systems needed to continue to embed to ensure those concerns are identified and sustained.
 

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 understood the importance and benefits of working alongside other professionals. The registered manager confirmed they had collaborated with external safeguarding teams in the investigation of accidents or incidents. We saw examples of joined up working where people had been referred to healthcare professionals and staff had successfully followed their advice and guidance to improve outcomes for people. For example, one professional said, “I have worked alongside the Chapel and District Bespoke Care team for several years. Contacting the team is a simple phone call or email for clarity. Confidentiality is always respected with only vital information being discussed [and either] information is available at hand otherwise the team will clarify and respond quickly.”
 

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

There were a range of monitoring and audit tools to assess and monitor the delivery of care and support to people. However, the audits did not identify all the concerns mentioned in the report. Some opportunities for learning were missed as audits were not consistently identifying when improvements were needed. The provider was responsive and open with the inspection process, listened to our recommendations and demonstrated a willingness to learn and improve.