2M Health & Home Care Services 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 rating has 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 breach of legal regulation in relation to governance at the service.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Improvements were needed to ensure governance was more robust and effective in managing the day-to-day quality assurance of the service. This would help ensure actions identified in quality audits were followed through and embedded into the service. Management had meetings with staff to discuss the expectations of the organisation and any concerns they had. Staff undertook a range of training to help ensure procedures were followed. There was regular communication between staff so that they could share their experiences and learn from one another. The registered manager told us, “Our key values are, compassion, dignity and respect, choice and control, safety, inclusion and learning and accountability.”

The registered manager was experienced and had worked at the service for a long time. Staff told us management were knowledgeable and provided them with the support they needed to do their job effectively. A member of staff said, “We have good staff communication, and the service is well organised.” Despite positive feedback from staff, this inspection found that management did not demonstrate clear insight into issues affecting the quality of the service. Whilst the management team completed audits and checks on the service, these had not identified issues, or concerns for the quality of the service. A service improvement plan was in place, but this plan failed to identify some of the shortfalls we identified at this inspection. At times the management were not clear on the number of people they supported with a regulated activity, and the support needs of these people.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager told us,“We have a confident challenge and exercise that, we encourage our carers you are not selling out your colleague or service user you are safeguarding them.” Staff told us they felt confident to speak up and their concerns would be listened to and acted upon. One staff member said, “We have to be able to whistleblow, to make sure things are done right”

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. One staff member told us, “They use questionnaires and welcome ideas and views to improve the service, they're always asking.”

At our last 2 inspections the provider had failed to operate effective quality assurance processes. This was a breach of Regulation 17. At this inspection, we found the provider had remained in breach of Regulation 17.

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 had systems in place to check the quality of the service. There were monthly audits of, medicines, infection control, complaints and care records. The audits were not always robust enough to highlight and manage shortfalls and areas for improvement in the service. For example,the medicines audits had not identified the concerns we found in relation to medication timings. Care records audits failed to identify daily notes were sometimes duplicated so could not be assured people’s needs were being fully met. Audits had also not detected that care plans and risk assessments were lacking detail and were not always up to date and accurate.

People and their relatives were not provided with accurate information about the previous inspection rating at all times. The provider failed to display their rating on their website, as required by law. We raised this with the registered manager who rectified this following the inspection.

People’s experience of the service was however positive, and we found no evidence that the concerns we had identified had impacted on the quality of people’s care. However, there was poor oversight and governance of the service which placed people at increased risk of harm.

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 was involved in forums and events to keep abreast of local and national developments in health and social care.An external stakeholder told us, “The recent recruitment of the deputy manager has improved this area [leadership], the provider has also appointed 4 team leaders in the field in February, and this has had a positive impact on communication across the service.”

The provider had failed to effectively monitor all aspects of the performance of the service. Records indicated that the service did not always focus on continuous learning, innovation and improvement. There were systems for learning, but these were not always put into practice. Accident/incident records did not always include information about lessons learnt and there was no information of action the service could take to try and prevent reoccurrence.

The registered manager told us they had reviewed the feedback we gave them as part of the onsite and offsite assessment process and were using the feedback to make improvements to the service.