Agathah 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 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.

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

This service scored 54 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. There were no opportunities for staff to discuss the organisational culture and values. No staff meetings or support sessions had taken place and there was no evidence that the providers priorities were discussed and actioned.

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. Although policies and procedures were in place, the provider had not always worked in line with them. For example, staff had not received training and development while being employed by the provider and their competencies had not been assessed. However, we spoke with relatives who told us the registered manager was approachable.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff had access to the whistle blowing policy and told us they would use this if required. The provider supported staff to raise concerns and to challenge any unsafe practice they witnessed.

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 relating to equality, diversity and inclusion. However, at the time of the inspection, staff had not received training on equality and diversity so we could not be assured that staff understood protected characteristics, bullying and harassment.

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 service was not consistently well led. The registered manager did not ensure governance systems were effectively used, and they had failed to identify shortfalls in the service. Quality assurance systems were not effective in ensuring people received a consistently good service and were not effective in identifying areas for improvement. Provider oversight of care planning, risk management and the quality of care being provided was poor. A governance framework was in place but had not been used, therefore the management team had not been proactive in identifying concerns.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Due to the size of the service there had been limited opportunities to share information and learning with partners and collaborated for improvement. However, we received positive feedback from external professionals who told us they had been involved in people’s care and support.

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. The provider had not implemented their governance framework. Therefore, there had been no evidence of lessons learnt when things went wrong, and no evidence of improvements made to develop the service. Opportunities for gaining feedback from people and their families had been missed. The provider’s systems and processes for learning and improvement were in place but needed to be applied and embedded in to practice.