Excellence Healthcare Services 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 good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 79 (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. The provider’s values were shared in the service user guide and put people at the centre of their care. The registered manager supported staff and ensured they reflected the provider’s vision and values during care provision. During staff meetings the registered manager held ‘values check ins’ to ensure staff continued to adhere to and display the provider’s values and behaviours.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

A knowledgeable and skilled leader was in place. The registered manager was up to date with best practice and was well informed about wider health and social care initiatives and research. They regularly consulted best practice institutes such as the National Institute for Care and Health Excellence (NICE) and attended skills for care forums and the Surrey Care Association. They attended monthly meetings where they met other providers and shared ideas. The registered manager was committed to developing themselves to become a positive leader and had employed a business consultant who supported them and gave them regular supervision.

The registered manager had an open approach and was responsive to their staff team’s needs. One staff member said, “I feel safe raising concerns with my manager because [they are] always quick to respond to all my concerns and ensures that all concerns are addressed promptly.”

The registered manager was aware of and adhered to their CQC registration requirements.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. A staff member said, “I know I can raise concerns without being scared, and it will be taken seriously.” Two staff had been nominated as freedom to speak up guardians, so staff had a named person to go to where they could raise concerns in a safe manner.

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them.

There was an inclusive staff team and the registered manager ensured Excellence Healthcare was a safe workplace. The registered manager told us, “Care workers are from different cultures and backgrounds so we make sure everyone is included. We celebrate different religious festivals and key events. We make sure we give staff time off when they are celebrating.” Staff felt safe and respected whilst working, they felt included in the service and in decision making. There was a collaborative approach to service delivery that reflected the needs of staff and people from different backgrounds and cultures.

Many of the care workers were overseas workers and the registered manager understood and had empathy for how big a change this was for some people to move country, where they did not have their usual support structures. The registered manager had introduced a buddy scheme to help new staff settle into their role, but also to settle into the country and within a different culture. They found this system gave staff someone to talk to if they had any concerns or worries, and helped them to develop their confidence to approach, speak openly and if required challenge their managers.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The registered manager had incorporated systems which alerted any quality or safety concerns. This included identifying if staff were running late for calls, highlighting if care needs had not been delivered and identifying if a medicine had not been given. There were regular spot checks undertaken to review staff practice and observe performance to ensure staff were adhering to the provider’s policies and procedures. Staff found this to be a supportive process. A staff member said, “These processes help make sure the care is good and we are doing our job well.”

In addition, the management team obtained feedback from people and their relatives about care delivery. A relative told us, “The staff in the office frequently check in by both phone and email to obtain feedback about how things are going. There is also a feedback form sent out at intervals to fill in too.” The feedback received was overwhelmingly positive.

Governance and quality assurance meetings were held regularly to review the quality and safety of care provision, review staff’s adherence with key performance indicators and adherence to best practice guidance.

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 worked in partnership with their staff team and the people using the service. Staff said they were “frequently” asked for their views and suggestions about how to care for people and how to improve service delivery. There was a team approach to service delivery and staff felt included in decisions.

Relatives also felt listened to and involved in the service. A relative told us, “The office are approachable and quick to respond to any request that I make. They listen well and work collaboratively with us to give [their family member] the best quality of life possible. They are always friendly and open.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

There was a commitment to learning and improving the service and staff performance. A staff member told us, “I have chances to grow and get better at my job.” There was a drive to provide high quality care and the registered manager had clear ambitions for the service. They said, “We want to be one of the best care agencies in this community. We are working on continuous improvement. We want to provide trusted care.” A business improvement plan was in place which had been developed with input from the whole staff team, so there was ownership and engagement in the process which reflected the needs of the business, staff and people using the service. The registered manager said, “The business improvement plan is co-created and we involve care workers, looking at what we want to do and how we are going to do that.”

The management team had plans to pilot a new initiative in line with NICE guidance published around falls reduction, through early identification and treatment of urinary tract infections. The registered manager told us, “We have looked at the NICE guidelines about falls and hospital admissions. We are looking at buying our own kits so we can do timely urine analysis. So, we can hopefully speed up the process so clients get their care and treatment quicker and hopefully cut down on falls.” We will review the impact of this project at our next assessment.