Warrens247 Healthcare 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 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 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.

The service had a clear vision supported by agreed values and policies, which were shared with staff via a staff handbook. Staff received regular supervisions and appraisals and attended team meetings. Staff told us they felt supported in their roles and morale within the team was good. A staff member said, “The manager is easy to talk to and takes everyone’s concerns seriously. It’s a good place to work. I enjoy getting to know people and making their day better. It’s rewarding work.” Due to concerns we found in relation to safety and care records, we could not be assured all staff had up to date guidance to follow or understood their roles and responsibilities in relation to accidents.

Not all leaders understood 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. Due to concerns found during our inspection, we could not be assured the leadership and governance of the service was good. The provider’s statement of purpose contained details of providing support to people they were not registered with the Care Quality Commission to provide. Following our assessment, changes were made to the providers statement of purpose. Business continuity plans were in place, to guide staff about what to do in emergency events, such as severe weather.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There were clear whistle-blowing procedures in place and staff told us they felt comfortable to whistle-blow and action would be taken. People and relatives felt listened to and told us they could speak with staff or management teams if they had any concerns. A relative said, “They have provided a booklet which has a list of numbers I can contact if there were any concerns. I have never had to make any complaint.” Staff communicated via an app and told us communication amongst the team was good.

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. Policies and procedures were in place in relation to promoting equality and diversity within the staff team. Staff felt supported in their roles and told us no one had been subject to any 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. Whilst governance systems were in place, such as regular auditing of medicines, IPC, safeguarding, care records and staff practice, these had failed to identify the concerns we found in relation to managing risks, learning lessons, care plans, training and managing medicines. We also found an incident which we had not been notified about, in relation to a safeguarding concern. This was brought to the attention of the registered manager during our inspection and notifications were submitted to us retrospectively.

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. Improvements were required to ensure staff contacted the appropriate external professionals following people having accidents. Partners told us they had no concerns about the service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. There were a lack of ongoing quality improvement systems. Whilst the provider had audit systems and sought feedback from people, there was no ongoing service development plan to recognise and work towards improving the quality and safety of the service.