Delight Services Limited Also known as Delight Care

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 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 breach of legal regulation in relation to governance.

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.

Staff were clear about the provider’s expectation of them and demonstrated the provider’s values in their day‑to‑day practice. A staff member said, “Our aim is to provide care and support to meet the needs of people who we support by providing good quality care, to enable people and be supported to live independently in their homes.”

The registered manager, in discussions with us, demonstrated a commitment to providing people with consistent care and support that was responsive, flexible and promoted equity and equality.

A person who used the service and a relative told us how the service was priced fairly and offered good value, and this was important to them.

Although the provider demonstrated an awareness of the context in which care, treatment and support were delivered, there were notable shortfalls in how effectively this understanding translated into the management of the service. While the provider possessed relevant skills, knowledge and experience, concerns remained about their ability to apply these consistently in practice.

Despite the registered managers intention to lead with integrity, openness and honesty, weaknesses in oversight and operational management showed that these values were not consistently embedded across the service.

The registered manager and provider had not fulfilled their registration regulatory responsibilities of reporting notifiable incidents as required.

The PIR and additional documents such as internal audits shared with us, did not accurately reflect the service we found. An example of this was reported under the Key Question Responsive.

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

The provider had systems and processes, including policies and procedures such as Freedom to Speak Up, Whistleblowing and Safeguarding to support staff to raise any concerns.

Staff felt confident speaking up when required. They told us they found the registered manager to be supportive and approachable, and they had regular and consistent contact with them. A staff member said, “I feel confident to raise any issues or concerns with the manager.”

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 confirmed the registered manager was fair and treated them equally and they had not experienced any form of discrimination.

The registered manager told us and staff confirmed, reasonable adjustments were made to support staff in their role.

The provider had an equality and diversity policy that reflected the Equality Act 2010. This protected both staff and people using the service against any form of discrimination.

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.

The provider’s governance systems, processes and procedures that assessed risks, and monitored quality and safety were not fully effective. They had failed to identify the shortfalls we found during this inspection.

For example, people’s pre‑assessment, care plans and risk assessments lacked detail and in places recorded no information. This meant staff did not have the guidance they needed to understand people’s needs, preferences or risks, increasing the likelihood of inconsistent care, unmet needs and unsafe practice.

Oversight and review procedures of people’s care lacked formal structure and consistency. The review documents shared with us did not provide sufficient detail about who was involved, what was discussed, or any meaningful actions and outcomes. This meant there was no reliable process to ensure care plans were kept up to date, risks were regularly reviewed, or that changes in people’s needs were identified and acted upon in a timely way. There had been an over‑reliance on informal practice and a lack of robust record‑keeping, which limited the provider’s ability to monitor quality and drive improvement.

Medicines management and processes did not reflect the provider’s medicines policy and national best practice guidance. The lack of staff competency assessments, audit and oversight procedures had put people at risk of harm.

Spot checks on staff were not formally recorded. Gaps in staff training and the absence of staff competency assessments demonstrated poor oversight and a lack of effective governance. The provider could not assure themselves that staff practice was being routinely monitored, that staff were sufficiently competent or that concerns identified were followed up and addressed.

Policies were inconsistent in detail or correctly reflected the service. This meant staff did not have clear, accurate or up‑to‑date information to follow, increasing the risk of inconsistent approaches, poor decision‑making and care that did not align with best practice or regulatory requirements.

The provider’s complaint and quality assurance procedures were confusing, due to the information reported in the provider’s audit not reflecting what the registered manager told us. Without supporting evidence of complaint and incident reports, analysis and actions, it was not possible to determine whether concerns were being appropriately recorded, investigated or used to drive improvements. This lack of transparency and assurance increased the risk that issues would go unaddressed and that learning would not be embedded across the service.

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 gave examples of making referrals to external health and social care professionals for assessment, guidance and support when people’s needs changed and to improve people’s quality of life and outcomes. This included raising safety and wellbeing concerns.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The shortfalls in systems and processes reflected in this report demonstrated how improvements are required in leaning, improvement and innovation.

The registered manager told us they were responsible for all aspects of running the service and acknowledged this had impacted their ability to ensure systems and processes were as effective as they could be. This lack of capacity meant opportunities to review practice, learn from shortfalls and drive improvement were limited.

The provider’s service improvement plan did not reflect any areas for development or actions required to address any shortfalls identified. It lacked meaningful analysis, clear priorities, timescales or measurable outcomes, making it difficult to see how the provider intended to drive improvement or ensure the service continued to develop in line with people’s needs and regulatory requirements.