AQS Hampshire East

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 good. At this assessment 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 service was in breach of legal regulation in relation to the governance of the service and poor record keeping. Governance procedures were not always effective. The provider had not identified all the quality, or risk concerns we found during our inspection. This meant prompt action had not been taken to address shortfalls.

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. Staff knew the aims and values of the organisation and management told us they went through the values of the service as part of the induction for new staff.

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. The manager was going through the process of registering with the CQC to become the registered manager for the service. Staff told us the manager was open and honest, and they were able to contact them when needed and felt fully supported by them.

However, we identified a breach of legal regulations and concerns relating to records and governance. Leaders had not independently identified or acted on these issues prior to our assessment. We also found inconsistencies in the provider and manager’s understanding of records and assessments, including those related to environmental risks and medicine management. This meant some development was needed in their skills and knowledge to lead effectively.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had appropriate polices in place as well as a policy on Duty of Candour to ensure staff acted in an open and transparent way in relation to care and treatment if people came to harm. The manager told us people had information in their folders in their home about how to raise concerns. Staff we spoke with were aware of how to raise concerns.

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 to promote diversity and equality were in place. The manager told us how they supported staff and valued their beliefs by making reasonable adjustments to staff’s working patterns to support their diversity.

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.

Improvements in records relating to people’s care and the service were needed. The manager was unable to provide us all the information requested. This included service improvement plans, copies of staff minutes, care plan audits and reviews.

The provider also needed to ensure their auditing processes were clearly documented and effective in promoting safety and good quality care. For example, the provider’s good governance policy and procedure stated, ‘The Registered Manager must ensure that quality assurance audits are completed in accordance with their policy’. However, we saw this was not always in place. No records were provided to evidence the manager’s audit process. The only audits provided by the manager during the inspection were related to medicines. However, we had concerns about the accuracy and effectiveness of these audits. For example, all entries were ticked to indicate that no issues had been identified, yet we found gaps in people’s medicine records. This raised concerns about the robustness of the audit process and whether it was being used effectively to identify and address areas for improvement. The provider told us they visited the site at least once a month to audit the service and maintained remote oversight to follow up on any concerns with the manager and ensure appropriate actions were taken. Following feedback during the inspection, the provider sent us a copy of one of their audits. However, this audit did not cover all areas as outlined in their policy, and it was unclear what actions had been taken to address identified issues or drive improvements.Following the inspection the provider sent us further audits of the service..

The manager and provider were unable to demonstrate that thorough oversight of the service was in place, therefore the shortfalls we found had not been identified prior to our inspections.

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 leadership team and staff worked effectively with health and social care professionals to meet people’s needs. Staff had undertaken reviews with relevant healthcare professionals as people’s needs had increased and made referrals to occupational therapists, community nurses and GPs when needed.

The provider and manager were motivated to work towards continuous learning and improvement across the organisation. They told us they had an action plan with areas of improvement, although they did not provide a record of this. Although the provider was motivated to learn and improve the service for people, their overall ambition was limited by the lack of established risk and quality monitoring systems. This meant they might not always be aware of shortfalls to enable prompt improvement and learning.

We did not see any evidence of any staff meetings that took place to make improvements. One staff member told us, “We have staff meetings but not very often, normally when it’s going a bit wrong or a lot of calls needs covering, we don’t have regular meetings.”

We were concerned due to the lack of records and governance systems that improvements would not always be picked up and systems put in place to drive improvements to the service. The manager told us how assessments had been improved to explore more about diversity and people’s human rights.