TheSignLife Project

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 systems and processes in place to assess, monitor, and mitigate risks and make improvements were ineffective. Care plans and risk assessments lacked consistency, and training or quality assurance processes were not robust or effectively followed. As a result, the service failed to identify the concerns highlighted during the assessment. The service was in breach of legal regulation in relation to good governance at the service.

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 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.

Leaders promoted an inclusive and supportive workplace culture. Staff mostly told us they felt respected, valued, and listened to. One staff member said, “The management staff in the company listen to me if I have a problem or concern with a client and support me.” Another told us, “Workplace culture is very good and very inclusive and I feel safe and respected in my work.” There was a strong sense of teamwork and mutual support. Staff described a culture where colleagues looked out for one another and for the people they supported. The provider had a clear vision for the future of the service, which included expanding interpreting services and increasing deaf awareness in the wider community. Leaders demonstrated a strong commitment to working with people who are profoundly deaf and developing services that met their specific needs. Staff spoke about long-term goals such as establishing a deaf day centre or residential service, and the importance of recruiting and training staff with the right skills, including sign language proficiency. Staff described the service as having an “open door” culture, where they felt confident to approach management. Newer staff told us they felt well supported and encouraged to develop their skills. One said, “When you are nervous on your first day, I felt the staff have been very supportive. They have always been there when I needed them. I feel very independent to do my role.” The provider demonstrated an understanding of the challenges in delivering high-quality, person-centred care and staff and leaders shared a passion for the service and a clear understanding of its values and direction.

Leaders did not fully understand the context in which the provider delivered care, treatment and support.

While the registered manager was supported by the immediate office team, there was no support available at provider level. This limited opportunities for professional development, collaborative problem-solving, and external networking. The registered manager had not explored links with other registered managers or external groups to share learning or seek advice. There were gaps in leadership oversight and governance. For example, there were no safeguarding logs in place, and the manager lacked confidence in when to report safeguarding concerns to the Care Quality Commission. No safeguarding notifications had been submitted in the past 12 months, raising concerns about the service’s ability to recognise and escalate safeguarding issues appropriately. Although staff told us they could contact someone out of hours, the response was not always timely. This could impact the support available to staff during emergencies or when making decisions about people’s care. Spot checks of staff working in the community were not documented. While some staff were aware that spot checks had taken place, others were unsure. The manager explained that they avoided using the term “spot checks” to reduce anxiety. However, without a clear process or documentation, staff may not know what to expect, and the service cannot demonstrate effective oversight of care delivery. The provider has now however put a form in place to document observations.

Despite these concerns, the registered manager demonstrated inclusive and thoughtful leadership in day-to-day interactions. They were mindful of how facial expressions are interpreted in British Sign Language and ensured staff fully understood what was being communicated. During face-to-face training, the registered manager took time to check understanding and used person-centred examples to support learning. This showed a commitment to inclusive communication and staff development. Staff and relatives told us they were overall happy with how the service was run.

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

Staff were aware of the whistleblowing policy and understood how to raise concerns. One staff member explained, “If you see something that isn’t right ...you are able to report that confidentially in line with the policy.” Another told us, “The management staff in the company listen to me if I have a problem or concern.” Staff described management as supportive and accessible. Another staff member explained their approach: “I would speak to the team leader. If that does not work, I would go higher.” This showed a clear understanding of how to escalate concerns appropriately.

While policies around speaking up were generally thorough, they were not always tailored to the specific needs of the service. For example, the complaints policy referred to verbal, electronic, or written communication but did not mention British Sign Language (BSL) friendly alternative. Although staff confirmed they had access to interpreters and knew how to raise concerns, the omission may reduce accessibility for some individuals. Whilst one staff member did express that it could be difficult to raise certain concerns with specific individuals, the overall experience was that the culture supported openness and transparency, and staff felt confident that their voices would be heard.

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 service actively supported people who were profoundly deaf to work, demonstrating a commitment to inclusive employment practices. Staff told us they felt listened to by the provider and confident that their voices were heard. One staff member said they felt supported and able to raise any concerns. The provider ensured they were regularly available to staff, arranging supervision and team meetings. These meetings gave staff the opportunity to engage with them. Staff told us they were happy working for the provider and felt they were treated fairly. There were procedures in place to consider individual needs and ensure all staff were treated equitably. This helped to foster a positive and inclusive working environment.

The provider did not have clear responsibilities, roles, systems of accountability or good governance. Whilst some processes were in place there was a lack of documentation or evidence to support this.

Risk assessments included references to individuals’ capacity but lacked detail on how staff should respond to specific behaviours or risks. For example, one person’s plan noted they may “switch off” but did not explain how staff should respond. This could lead to unsafe care, particularly for unfamiliar staff. Access to individuals care plans was limited. A relative told us they previously had access to paper records but could no longer view their loved one’s care plan or daily logs following a move to electronic systems. They were unaware that access could still be requested. Feedback from people using the service was gathered during reviews, but this was not recorded. Without documentation, there was no evidence of what was raised or how it was acted upon to support care and treatment.

Incident records lacked detail and outcomes. While the manager could explain actions taken, there was no written documentation to support learning or identify trends. There were no safeguarding logs in place, and the manager lacked confidence in when to report concerns to the Care Quality Commission. Daily system checks to audit what had or had not been completed the previous day were carried out by the office team, but these were not documented or reviewed over time. This limited the provider’s ability to identify patterns or make informed decisions about service improvement. Spot checks of staff working in the community were not documented and did not seem to have a clear process, although the registered manager has now put documentation into place. Management meetings were held regularly, but no formal records or action plans were kept. Without documentation, there was no audit trail of decisions made, progress tracked or continuous improvement. The business continuity plan had not been fully completed. While it included risk descriptions and mitigation strategies, there was no evidence of actions taken or plans for managing incidents. The service’s website did not display the required widget to show that it is registered with the Care Quality Commission but currently unrated and so this may mislead the public and reduce transparency.

Whilst staff meetings were held regularly and minutes were shared with all staff, this was one of the few areas where communication systems were consistent. Recruitment files were disorganised. During the inspection, the manager struggled to locate key documents, such as identity checks. This could delay safe recruitment decisions and affect compliance. The medicines policy required staff to be trained and assessed as competent to administer medication, but no formal competency assessments had been completed. The policy clearly outlined what should be included in the care plan such as, health conditions and medication side effects, however it was clear from reviewing care plans that this was not being followed.

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 service only accepted referrals for people whose needs they could meet, primarily those who are profoundly deaf and use British Sign Language (BSL). People who became deaf later in life were signposted to other organisations better suited to their needs. This approach helped ensure staff were well-matched and able to provide safe, effective care.

Staff supported people to attend healthcare appointments and facilitated communication by accompanying them and arranging appropriate interpreters. For example, staff described working with a local GP surgery to support people who are deaf or deafblind, using both BSL and deafblind manual communication methods. This ensured people could communicate effectively with healthcare professionals. While we were unable to obtain direct feedback from healthcare professionals, staff confirmed they regularly supported people in this way. The provider maintained contact details for relevant professionals, including social workers and GP surgeries, and made referrals where appropriate. Although formal evidence of partnership working was limited, staff demonstrated a clear understanding of their role in supporting people’s health and wellbeing through collaborative working.

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.

Staff feedback was collected, but staff were unclear how their input was used or whether it led to improvements. One staff member told us, “Yes, I am asked for feedback which I do give. How this is then worked into future course development I do not yet know.” This lack of transparency may reduce staff engagement and limit opportunities for service development.

When things could be improved, staff told us these were sometimes discussed at team meetings. This was supported by meeting minutes, which showed meetings were sometimes used as learning opportunities. However, there was no structured approach to learning from events or sharing lessons across the team. Whilst the provider was not involved in any research, awards, or sector-led improvement initiatives to further develop the service or contribute to wider learning, they did utilise the technology they have to support improvement at the service. For example, digital records were used to evidence when additional time was needed to support individuals, which helped inform funding requests.