Daffodil 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.

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.

The service was in breach of legal regulation in relation to governance at the service.

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.

The provider did not demonstrate a clear shared vision or strategy to ensure care was consistently delivered in line with principles of transparency, equality, inclusion and person-centred care. Systems and processes had not been effective in identifying concerns found during this inspection.

There was limited evidence of a culture of continuous learning and improvement. The concerns identified during the inspection, including issues relating to care planning, risk management, communication and governance, had not been recognised or addressed by the provider prior to our visit. This meant opportunities to improve outcomes for people had been missed.

The provider did not always demonstrate a full understanding of the challenges experienced by people using the service or consistently seek feedback to drive improvement. As a result, people were not always assured that their views and experiences informed how the service was developed.

However, staff described a positive and supportive working culture. Staff told us they felt listened to by managers and were able to raise concerns, share ideas and seek support when needed. They described good communication within the staff team and positive working relationships with colleagues.

Following feedback, the provider told us they had developed a service improvement plan to address the concerns identified during the assessment. The plan included actions aimed at improving care planning, risk management, communication and oversight of the service. The manager told us they were committed to making the required improvements and driving positive changes to improve outcomes for people.

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 provider was passionate about leading the service and demonstrated a commitment to achieving positive outcomes for people. Throughout the assessment, the registered manager engaged openly with the inspector and responded positively to feedback provided. They expressed a commitment to undertaking the actions needed to achieve compliance with regulatory requirements and improve outcomes for people.

Staff spoke positively about the registered manager and described them as approachable, supportive and accessible. They told us they felt comfortable seeking advice, raising concerns and discussing issues affecting people's care and support. Staff said they felt listened to and supported in their roles, which contributed to a positive working culture.

Staff told us management were responsive, supportive and readily available when guidance or assistance was needed. Staff said they felt able to contact managers for advice and were confident concerns would be listened to and addressed appropriately.

Staff described having regular supervision sessions and team meetings, which provided opportunities to discuss their role, reflect on practice and raise any concerns. Staff told us they felt comfortable speaking up and felt their views were valued by the management team. This helped to promote open communication and a supportive working environment where staff could seek guidance and share feedback about people's care and support.

Despite staff reporting a positive culture of openness, there was limited evidence to demonstrate how concerns, feedback or lessons learned were systematically reviewed, shared and used to drive service improvement. Although staff felt supported to raise issues, the provider could not consistently demonstrate that feedback led to effective action or sustained improvements in practice.

The provider promoted an inclusive and supportive culture where staff felt valued, listened to and treated fairly.

Staff told us they had regular opportunities to share feedback through monthly team meetings, supervisions and appraisals. Team meetings were held through WhatsApp video calls and provided opportunities to discuss concerns, training needs, learning from incidents and service developments. Staff told us they felt respected and empowered to share ideas and raise concerns. Meeting minutes were shared with staff unable to attend and managers were available to discuss any issues separately to ensure all staff had the opportunity to contribute.

Staff described supervisions as supportive and inclusive. These meetings provided time to discuss wellbeing, workload, performance, training and career development. Staff felt comfortable raising questions and concerns and were confident they would be listened to. Staff also reported being supported to access additional training and professional qualifications to support their development and career progression.

The provider had policies and training in place relating to equality, diversity, bullying and harassment. Staff completed training to help them understand equality, equity, protected characteristics and how to recognise and report discrimination, bullying or harassment. The bullying and harassment policy outlined responsibilities, reporting processes and investigation arrangements.

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.

The provider's governance systems were not always effective in identifying, monitoring and addressing areas of concern. Audits completed by the provider had not identified issues found during the inspection, including concerns within daily records, medication administration records and care plans. This meant management oversight had not been sufficient to assure the quality and safety of the service.

Where audits had identified concerns, records did not consistently demonstrate that appropriate action had been taken. Actions relating to identified issues were limited or inconsistently documented, making it difficult to determine whether improvements had been completed, monitored or sustained.

Staff told us managers completed spot checks and competency assessments to monitor practice and support performance. However, documentation was not consistently available to evidence the checks completed, the findings identified or any actions taken as a result. This limited the provider's ability to demonstrate effective oversight of staff practice and assure themselves that staff were consistently working in line with expected standards.

The provider demonstrated a commitment to improving the quality of the service and was receptive to feedback provided during the inspection. They acknowledged the concerns identified and told us they had begun implementing additional systems and processes to strengthen oversight, improve record keeping and support service improvement.

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.

The provider told us they worked in partnership with health and social care professionals to support people and achieve positive outcomes. However, records shared during the inspection contained limited information regarding professional involvement, and there was little documented evidence to demonstrate how partnership working had informed people's care and support.

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.

Governance and quality assurance systems had not been fully effective in identifying the shortfalls found during this inspection. Audits and oversight processes failed to identify concerns relating to care records, medication records and care planning documentation. As a result, appropriate action had not always been taken in a timely way to address concerns, mitigate risks and drive improvement.

The provider responded positively to the feedback received during the inspection and took prompt action to begin addressing the concerns identified. This included reviewing existing systems and processes and introducing measures intended to strengthen oversight and support service improvement.

The provider demonstrated a willingness to develop their leadership skills and improve practice. They told us they were completing a leadership level 5 course, planned to join a local registered managers' forum and attend workshops to support their learning, development and understanding of good practice. These actions showed a commitment to strengthening management oversight and improving outcomes for people using the service.