Vitality Plus Care 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.

At our last assessment we rated this key question requires improvement. At this assessment the remained 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 service was in continued breach of legal regulation in relation to governance at the service.

This service scored 62 (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.

Staff were aware of the service’s values and aims. Overall, they told us they enjoyed working for the organisation and felt well supported. Staff said they could contact the registered manager for assistance whenever needed, including outside of normal working hours.

The provider demonstrated an understanding of the potential risks facing the service and had plans in place to address these. A business plan outlined the key priorities, including future staff recruitment and areas for training and development. The registered manager described the service’s culture as, “Our moto is we care like family when providing care.”

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.

The registered manager had support from a paid consultant who had oversight of risk and audits within the service. There had now been some improvement made at the service by the registered manager since the last inspection. For example, the registered manager now knew their responsibilities in relation to sending notifications to CQC. Documentation and files were well organised and managed.

We discussed succession planning with the registered manager, who told us that one staff member was completing a level 5 management qualification to support and strengthen the service’s leadership structure. Another staff member was undertaking a level 3 qualification to progress in their role. The registered manager also attended local events and engaged with other providers to share learning and enhance their knowledge.

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

Staff we spoke with told us they felt able to speak up and have their voice heard. They were aware of external agencies where they could also raise their concerns.

There was a comments and suggestion box, and staff had access to regular supervisions and team meetings. We saw comments from staff which were addressed by the registered manager.

There was a whistleblowing policy and procedure available.

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.

Staff told us they felt they worked in a fair and inclusive environment. They reported no experiences of discrimination, bullying, or harassment and said the team worked cohesively. They felt inclusivity was essential to delivering good‑quality care and support. Staff also gave examples of reasonable adjustments that had been made to accommodate their individual needs.

Equality, diversity and inclusion, and wellbeing policies were in place, and staff received annual training in these areas.

Prior to our inspection the provider had had reviewed their governance arrangements and introduced newly implemented monitoring systems. However, these were not yet fully effective at the time of our inspection

We still identified governance concerns at the service. Systems and processes in place had not identified the concerns with recruitment checks not being completed, which meant the provider could not always demonstrate staff had been safely and appropriately recruited in line with their policy and legislation.

We also still found instances where audits had not identified information was missing, inconsistent, or incomplete in relation to assessments, care planning and risk assessments. This meant staff did not always have access to accurate and reliable information needed to deliver safe and effective care.

Governance processes relating to medicines management were not always effective, which meant the potential for unsafe practice and increased risks to people.

Systems and processes had not identified or ensured Mental Capacity Assessments (MCAs) were completed for people who lacked capacity. This meant people’s capacity was not always being formally assessed, and decisions may not have been made in their best interests, as required under the Mental Capacity Act 2005.

Although we could not demonstrate any harm had come to people due to the governance concerns, we found there was a potential risk of harm to people because systems were not always effective.

However, new quality systems had been added since the last inspection to strengthen the oversight of risk and performance. For example, a real-time digital system. Regular audits were being carried out, and these identified areas requiring improvement. The most recent care plan audit recognised shortfalls in governance practices and outlined the necessary actions to address them but this had not been embedded at the time of the assessment. Policies and procedures were in place to support governance, and a Business Continuity Plan (BCP) provided guidance for managing emergency situations. The provider was also submitting statutory notifications to CQC as required.

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.

People and their families told us the service regularly communicated with relevant professionals on their behalf, which helped them feel supported and well‑informed.

The provider had working relationships with external agencies, including GPs, occupational therapists and social workers, contributing to improved outcomes and continuity of care for people.

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. They contributed to safe, effective practice and research.

The provider shared an example of recent discussions with the local authority regarding the quality of information received when new care packages were accepted. This had contributed to wider discussions about how risks were managed when people began receiving support. Staff were supported to achieve additional qualification to strengthen their skills and knowledge. The registered manager was also exploring a Level 6 qualification in quality improvement to strengthen their skills in this area.