Asher Excellent

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 inspection we rated this key question inadequate. At this inspection 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.

The provider was previously in breach of the governance legal regulation of the service. Some improvements were found at this inspection, but further improvement was still required. The provider remained in breach of this regulation.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider was passionate about achieving a good service and this was shared with the staff group. The provider and staff understood the importance of person-centred care and this was confirmed to us in the feedback we received.

The provider was an inclusive leader who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Whilst the provider led with integrity, openness and honesty, they did not always have the skills, knowledge and experience to lead effectively.

The feedback we received from staff about the provider was positive. Individual staff supervisions took place and informal meetings included staff to reflect on areas of improvement and professional development needs. However, the provider was still in the process of developing their own skills, knowledge and experience. The provider was experienced in the ‘hands-on’ care but told us they still had a lot of learn in running a service as a provider. This meant some systems and processes were not yet in place for us to assess.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There were no formal staff meetings, but as the staff team consisted of only 3 members, the provider worked alongside and met with them regularly and gained their feedback, and staff feedback forms were available. Staff felt they could share ideas and were listened to. The provider assured us that as their business developed, they would formalise staff meetings.

There was a complaints policy, and no complaints had been received.

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 were in place to promote the equality and diversity of the workforce. Processes related to recruitment were robust and staff were recruited in a safe way with pre-employment checks being undertaken. Staff completed equality training to develop their awareness about protected characteristics, bullying and harassment.

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. Governance arrangements at the service were not always effective and failed to ensure effective oversight on the quality and safety of the service.

Eight months prior to our inspection, the provider had moved their office location. Whilst they had tried to share their new address with us, this had not been completed correctly, resulting in the provider working from an unregistered address for over 8 months. As a part of our inspection, we asked the provider to urgently address this which they did.

Prior to our inspection, we reviewed the provider’s website that stated they had ‘partners’ which they worked collaboratively with. We advised the provider how the wording of this may be misleading to members of the public. They took immediate action to remove this from their website.

The provider showed us their IT system which had functions available for them to run specific reports. However, no information had been input by the provider so any reports run would have been empty of any information. The provider told us they were in the process of learning what was available to them on their IT system and had yet to develop effective systems and processes to audit the quality and safety of the service. This meant that there were no audits on the quality and safety of the service for us to assess.

The provider told us that due to their business being very small at this time, most of their checks on the quality and safety of the service were informally completed and checks undertaken were not recorded. However, informal checks were not always effective. For example, the operations manager drove staff to and from care calls using their own vehicle. The provider’s policy stated driving business insurance should be held but we found this had expired. Whilst the provider took immediate action to renew this, it reflected a lack of their oversight.

Where 1 care plan recorded that checks had been undertaken by the provider, this was dated the day of our inspection, this check did not contain accurate information and therefore would not have been effective in identifying areas for improvement.

The provider undertook one-to-one meetings with staff but these, and inductions into the service, were not recorded. This meant the provider could not refer back to conversations held with staff to check any actions required were completed. The provider told us they would make improvements to formally recording actions taken.

People using the service had no concerns about the management.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners or collaborate for improvement.

The provider’s operations manager told us that they had links with the district nursing team who they would contact if they had any concerns about a person’s skin and would follow any advice and guidance given.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

The provider was a member of a recognised organisation that offered services to support providers to learn and develop their service. However, whilst the provider demonstrated a commitment to achieving this, they could not evidence this in their systems and processes. The provider was keen to learn from our feedback and to get things right, but felt they had “much to learn to reach an outstanding service,” which they told us was their aim. For example, whilst the provider was aware of incidents they were legally required to tell us about, they were not yet familiar with the formats to be used and submitted to CCQ. The provider also told us that they had to balance the needs of developing their business with working in their employed job role, which meant they had limited opportunities for local networking and development. The provider’s operations manager told us they were in the process of completing their level 5 management qualification and hoped to then take a greater role in the service business development.