Head Office

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 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 the legal regulation in relation to governance at the service.

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 vision, strategy and culture that was not always shared with staff.

The provider spoke of a positive culture they had created for the service. It was unclear if staff were aware of the culture and direction or how they were involved with this. One staff member told us, “It’s not something that has been shared with me.”

We were not provided with any further information about the culture the provider aimed to develop for us to consider or review.

Not all leaders understood the context in which the provider delivered care, treatment and support.
A lack of understanding of the importance of effective governance systems from the provider meant the governance systems were not always in place or effective. This led to a lack of effective oversight of the service.
However, people and relatives were happy with how the company was run. One person told us, “I’m happy with the care. I am used to them, and they are used to me. I would miss them if they didn’t come.”
Care staff were aware of their roles and responsibilities and when they needed to escalate concerns.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People and relatives knew how to raise concerns and felt confident to do so. One relative told us, “I’ve not had to complain. I mainly email the office”.

There was a whistleblowing policy in place and staff were aware of this and the procedures they needed to follow.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for the people who worked for them.

Staff told us they were happy working within the company and felt they were treated fairly. There were procedures in place to consider staffs’ individual needs and ensuring all staff were treated equitably.

There were not always effective systems in place to make changes and identify areas of improvement. Some audits were in place; however, they were not consistently completed.

There was no system in place to audit the care people received. Reviews of people’s care were completed, however some of these had not been completed since November 2024. Where we had identified concerns such as care plans not being in place for people’s assessed needs and information not accurately recorded, these reviews had not identified these concerns.

Although medicines administration records (MAR) were viewed on the ‘live system’ and random spot checks were completed with staff to ensure medicines were administered, there were no audits completed to ensure medicines were safely administered. There was no system in place that would have identified that staff were not having their competency checked in relation to medicines.

There was no effective system in place to ensure people had their calls delivered at their preferred time. The provider told us they checked the live system when they were in the office, and we saw they printed off a copy of staffs’ delivered care hours. After the site visit, they also sent us a visit timer for March 2025. However, this showed us that calls were often delivered late. There was no evidence this or any other information relating to calls were reviewed or checked to ensure care was accurately delivered to people.

A monthly governance meeting was held and documented quality issues within the service, however this was not always effective as it had not identified the concerns we have identified through this assessment process.

However, there was an effective health and safety audit completed and a learning log in place for care concerns and incidents and accidents.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

There were systems in place to ensure the provider worked in partnership with other agencies. As part of this assessment, we asked the Local Authority for feedback, and we received no concerns.

The provider did not always focus on continuous learning, innovation and improvement across the organisation.

There was a lack of effective governance systems in place to identify concerns and drive improvements within the home, which meant learning opportunities were missed.