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 question inadequate. At this assessment the rating has changed to 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 61 (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. They understand the challenges and the needs of people and their communities. The provider did not always offer opportunities for staff to discuss the organisational culture and values. The registered manager told us they tried to see all staff and people on a weekly basis, but this was not always documented. The registered manager told us their values were, “To treat each other as family. To treat the person how you would want your relative to be treated. Respect for each other and consider people as the main priority.”

Leaders understood the context in which the provider delivered care, treatment and support. Systems to embody the culture and values of their workforce and organisation required some further development. Leaders had the skills, knowledge, experience and credibility to lead effectively, and did so with integrity, openness and honesty. Since our last inspection, the registered manager had begun to see the importance of ensuring they had oversight of the service and had taken action to ensure the governance framework was utilised better. The registered manager had minimal staff and not always enough staff to meet people’s needs. This led to the registered manager having to deliver care which took them away from the management of the service. The registered manager had identified the need for more staff to allow more time to focus on the management and governance of the service. The registered manager planned to recruit more staff to ensure to facilitate this.

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 did not always value diversity in their workforce. They did not always work 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.The provider understood the needs of the staff and allowed staff to work flexibly to attend appointments. Equality and diversity training was part of the staff induction process. The provider had an equal opportunities policy and expected staff to listen and allow people the opportunity to influence their care. Staff were expected to treat people with dignity and respect regardless of their age, gender, disability, age, sexual orientation and religious needs.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Since last inspection the provider had introduced some audits to check the quality of the service. Monthly quality assurance audits took place and included a review of care notes and daily records, medication, spot checks, care plan audits, and risk assessments. Issues identified were actioned. Whilst the provider had made improvements to the governance framework, the systems and processes were newly implemented and required embedding in to practice to ensure they continued to be effective.

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 showed a commitment to partnership working and had developed good working relationships with professionals.

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. During this inspection we found improvements had been made based on learning from previous inspections. The provider had introduced staff knowledge assessments linked to policies and procedures to ensure staff had read understood the processes in place. However, the registered manager did not always have the opportunity to actively contribute to safe, effective practice and research. The registered manager was keen to improve the service and felt the pending recruitment of more staff would assist them to develop further.