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. This is the first assessment for this 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.

This service scored 50 (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.

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 a Service Director, 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, they were 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 Edenvale.

Some staff and healthcare professionals said staff did not always feel heard and, at times, chose not to raise concerns because they were worried about possible negative reactions.

The provider had whistleblowing policies and procedures in place. Information was clearly displayed should staff or people need it.

We saw team meetings took place, with an agenda, that facilitated staff input. 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 that all employees were encouraged to participate in. 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. Safeguarding concerns and referrals were not always submitted in a timely manner and when concerns were raised, staff and relatives, did not always receive an update or conclusive outcome. The provider did not always share concerns quickly and appropriately as statutory notifications about incidents of abuse had not been submitted to CQC. We raised this with the registered manager who submitted the notifications in retrospect. General oversight by the registered manager was lacking and 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 Statement of Purpose displayed incorrect service user band information however, the provider amended this immediately, following feedback, and submitted a notification of change to CQC.

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 provider’s ability to ensure all care staff were supported appropriately and rostered to ensure people’s needs were always met. The relationship with external stakeholders had not always been open and collaborative. There was concern from partners over accessibility and oversight from the registered manager and provider. The provider had produced an action plan which provided 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 relatives indicated that the service needed a registered manager who was present and actively involved in providing effective oversight and support to the local team. Staff said rotas had been created away from the service, without consideration of a skill mix and flexibility had impacted on activities offered to people. Staff and relatives also felt that activities, such as visiting family or accessing the community, had been cancelled on several occasions due to the lack of drivers on appropriate shifts or insufficient staffing numbers to have facilitated the planned activities.