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.At our last assessment we rated this key questionrequires improvement. At thisassessmentthe rating haschanged to inadequate.This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.The provider did not offer opportunities for staff to discuss the organisational culture and values. There were no meetings or group support sessions in place to ensure the provider could share their vision for the service.

Not all leaders understood the context in which the provider delivered care,treatmentand support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge,experienceand credibility to lead effectively, or they did not always do so with integrity,opennessand honesty.The registered manager could not evidence staff were informed of the providers policies and procedure to ensure staff knew how to meet expected standards. We found policies and procedures were in place but not adhered to. Forexample,the medication policystatedstaff should be trained and competent to administer medicines, however no staff were trainedin this subject. The provider’s recruitment policystatedstaff should be recruited appropriately and gave a full list of documentation including pre-employment checks that should be in place. However, we found lots of missing documentation and lack of evidence to support safe recruitment.

There was a governance framework in place, but this had not been used effectively. There was a lack of provider oversight, and theregistered managerwas the person carrying out most care, therefore, they didnot feel it wasappropriate tocheck their own work. However, there was no one else available to constantlyoverseethe service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff had access to thewhistleblowingpolicy and told us they would use this ifrequired. The provider supported staff to raise concerns and to challenge any unsafe practice theywitnessed.

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,diversityand 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,performanceand outcomes, or share this securely with others whenappropriate.At our lastassessmentthelack of an effective governancesystem had led to a breach of regulationin regard togovernance. We asked the provider to complete an action plan todemonstratehow this would improve. However, at this assessment we found continued concerns.The provider’sgovernance systemwasvery basic, but the provider had started to complete some audits, albeit infrequently.These included audits for medicine management, careplanningand spot visits to ensure staff were delivering safe care. However, the systems had notidentifiedissues we raised during the assessment, specifically around managing medicines andstaff recruitment. Systems required furtherdevelopment andembedding in to practiceto ensurethey were effective.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people.Due to the size of theservice,there had been limited opportunities to share information and learning with partners and collaborated for improvement. The registered manager told us no professionals were currently involved in people’s care, however, care plans reflected otherwise. This showed a potential for missed opportunities to work in collaboration.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience,outcomeand quality of life for people. They did not actively contribute to safe, effective practice and research.The provider did not have an effective governance framework in place to enable learning. Following the last assessment in August 2025, the provider sent an action planstatinghow they would address the concerns raised. At this assessment we found several areas had not been addressed such as management of medicines and safe recruitment of staff. 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.