Michdeede LTD

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 newly registered service. This key question has been rated 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 governance at the service.

This service scored 29 (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 or culture that ensured safe, high-quality care or supported learning and improvement. While the registered manager described a culture of “respect and equality”, this was not reflected in practice. Systems were not in place to support a consistent culture across the service. Staff told us they had not seen policies or procedures and did not have access to guidance to support their role, which limited their understanding of expectations and standards.

There was limited evidence of staff engagement or learning culture. Staff said they had not been asked for feedback or given opportunities to improve the service, and no questionnaires or structured feedback processes were used. This meant the provider was unable to demonstrate a shared direction or embedded culture that promoted safe, person-centred and consistent care.

Leaders did not have the skills, knowledge, experience and credibility to lead effectively.

Leaders were not effective in ensuring staff were competent, supported or equipped to deliver safe care. While staff described the registered manager as approachable and “supportive,” this was not reflected in how the service was managed. Leaders had not ensured staff received appropriate training, induction, supervision or appraisal.

Staff told us they had not completed any training at all and confirmed they were administering medicines without current training. There was limited oversight of staff practice and performance. Supervision and appraisal systems while in place were not being used. Recruitment processes did not ensure staff were suitably qualified or experienced. Leaders lacked the capability to ensure regulatory requirements were met and did not effectively oversee care delivery, resulting in risks to people’s safety.

The provider had not created an open culture where staff and others could confidently raise concerns and be assured these would be acted on. Staff were not familiar with safeguarding or whistleblowing processes and told us they had not been given access to these policies. This meant they required prompting when asked how they would escalate concerns.

Some staff were unsure who to report concerns to beyond the registered manager and required prompting to identify external agencies. There was also limited evidence of learning from concerns. Systems to record and respond to incidents, complaints or risks were ineffective, and there was no clear evidence that feedback was used to improve practice. This meant people and staff could not be assured that concerns would be listened to or acted upon.

The provider did not have effective systems to ensure workforce equality, diversity and inclusion were embedded in practice. Although the registered manager described a commitment to equality and non-discrimination, staff did not have access to policies or clear guidance on equality, inclusion or their rights.

There was no evidence of structured training in equality and diversity, support or reasonable adjustments for staff. Staff had not received mandatory training or development opportunities, which affected their ability to carry out their roles safely and effectively.

The registered manager told us they had booked staff to attend training with an external provider however, we requested confirmation of the date this was to take place and we failed to receive this information. Therefore, we were not assured training had been booked for staff.

In addition, recruitment processes were not robust, and did not demonstrate fair or safe selection practices, including missing references and incomplete employment checks. This meant the provider could not demonstrate a fair, inclusive or well-supported workforce. Staff described meeting the registered manager outside a shop to conduct their interview and being advised to commence work the next day without completing full employment checks.

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.

Governance systems were not effective to ensure the safety, quality and sustainability of the service. There were no quality assurance systems in place. Audits, including medicines and recruitment audits, were not completed, and records to demonstrate oversight of care were absent. Records were incomplete and not always accurate, including missing recruitment documents, lack of care monitoring records and concerns about records being created retrospectively.

Feedback from relatives also highlighted a lack of oversight and transparency, including being told staff were trained when they were not. This meant the provider could not demonstrate effective systems to manage risks or deliver sustainable improvements.

The registered manager sent us documentation they wanted to use to support them with governance but, this had not been implemented and therefore we could not be assured of its effectiveness.

The provider had not ensured regulatory requirements were met. There were breaches relating to, staffing and governance, and risks to people were not effectively monitored or mitigated.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider had some working relationships with partners, but these were not consistently effective in supporting safe and coordinated care.

However, partnership working was not always effective. Records did not consistently demonstrate communication or coordinated working with external professionals, and staff lacked clear guidance to support joined-up care. Relatives were present and sometimes involved with care, which helped mitigate some risks, but they had not always been involved in reviews or asked for feedback about the service. This meant partnership working did not always support safe, consistent or person-centred care.

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, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider did not have effective systems to support learning, continuous improvement or innovation. Systems to record and learn from incidents, complaints and concerns were not embedded. This included a lack of evidence of investigation, learning or changes to practice when issues were identified.

There was limited evidence of quality improvement activity. The provider described plans to introduce training and quality assurance processes, but these had not been implemented at the time of the assessment. Staff were not supported to develop or contribute to improvement. They reported limited training opportunities and had not been asked for feedback on how the service could improve. This meant the provider was not driving improvement or ensuring lessons were learned to enhance the quality and safety of care.