Archived: Creative Support – Carlisle Services

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 good. At this assessment the rating has changed to 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.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A clear, shared vision was still being developed by the provider to ensure their strategy and culture was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

However, the current structure of the service and the location of the management team did not provide enough oversight or support a shared direction. Although staff could contact the registered manager by telephone or email, their lack of full-time input to the service was perceived by staff as a significant lack of support and guidance.

Staff told us they considered the deputy or scheme coordinator as their immediate line managers. Healthcare professionals and family members expressed concerns over a lack of regular access to the registered manager.

The provider was recruiting for a new permanent registered manager. They told us they were implementing interim measures to address the issues raised.

The registered manager did not always understand the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

The registered manager did not demonstrate a good oversight of the service. There was a senior leadership team which consisted of operational managers, regional managers and a quality assurance manager. The registered manager told us they felt supported by their senior managers taking on this extra service whilst recruiting for a permanent registered manager.

The registered manager was very experienced; however, the registered manager was responsible for 2 services, and the significant distance between these locations was a complicating factor in providing consistent oversight and support. As a result, the registered manager relied heavily on support from the management team on-site and senior regional managers. This approach was not effective for staff and the people living at Burnside Court or Heysham Gardens.

People and relatives did not always know who the registered manager was. Most identified the deputy manager or scheme coordinator as their main point of contact and considered them the manager.

One staff member told us, “Not having a registered manager onsite since the end of last year has definitely had a detrimental effect on the running of the services. The deputy manager and scheme coordinator have at times been put under extreme pressure trying to run the two services, working excessive hours to try and get the work completed with very little help from management at head office.”

Comments from family members were mainly positive and included that local management were friendly, approachable and very nice.

The provider fostered a positive culture where staff felt they could speak up and their voice would be heard. The provider had whistleblowing policies and procedures in place. Information was clearly displayed should staff or people need it. We received limited feedback from staff. Those we spoke with told us they felt able and confident to raise concerns and were very clear that they would do so if required.
 

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 provider had a safe workplace procedure in place.

The provider had an Awards scheme and at least two staff members had been nominated for an award. One for ‘being calm, caring and supportive’ and another who had won for how well they responded to a serious incident. Other wellbeing initiatives included an Employee Assistance Programme and an Equality, Diversity and Inclusion Network which offered support and advice to staff and their families.

Some staff felt their wellbeing could be better considered with improved registered manager oversight and support.

When asked, no-one had experienced any discrimination.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. There were processes and policies in place for systems of accountability by the provider however, these were not always completed regularly. When concerns were raised, staff and relatives, did not always receive an update or conclusive outcome. General oversight by the registered manager in relation to assessing, monitoring and improving quality in the service was lacking. Although audits had been completed and recorded actions taken, there were some gaps in the documentation and supervisions and appraisals had not been completed regularly. There was a lack of clarity within the team regarding management responsibilities, and it was equally unclear which roles were accountable for specific tasks.
 

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.

Partners did not always have confidence in the registered manager’s ability to ensure all care staff were supported appropriately. External stakeholders felt that relationships were not always open and collaborative and were concerned over accessibility to and oversight from the registered manager. One external professional told us, “My concerns are the lack of management and leadership.”

The provider had produced an action plan which showed a framework and timeframe for improvement.

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, healthcare professionals, and relative indicated that the service needed a registered manager who was present and actively involved in providing oversight and support to the local team. Systems for checking and improving the service were in place. Although the manager, senior team, and quality team all reviewed audits, some records lacked detail. Safeguarding arrangements were in place, and concerns were reported to the local authority and CQC as required. We saw the details in safeguarding, notifications, and incident reports were brief, although the information included was relevant. Although there was a process for incident report reporting and learning was not consistently documented or embedded, and there was minimal evidence of a lessons-learned process following medication or care planning concerns. The provider was committed to improvement but the lack of effective oversight and support to the staff team had impacted this.