Clarissa's Home Healthcare 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 a legal regulation in relation to good governance.

This service scored 57 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. Staff told us the provider’s vision and values focussed on delivering safe, person-centred care, promoting dignity, independence, respect and they were committed to meeting the needs of people entrusted to their care. Staff also told us they were reminded regularly of treating people as individuals and supporting them safely. However, we found some elements of care were not delivered in line with the provider’s vision and values. For example, care was not always person-centred.

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. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The provider and registered manager did not always have the knowledge and skills to lead effectively. For example, their oversight, systems and processes were not always used effectively to ensure people received safe, high quality care.

Staff told us leaders supported their wellbeing during busy shifts by stepping in to help with tasks. Leaders were visible within the service, they had interpersonal skills, led by example and were accessible when needed. A relative told us when they spoke with the registered manager they were, “excellent” and, “they listened to us and acted appropriately.” A person told us when they had concerns, they spoke with the registered manager “and it was relatively easy to change things.”

The provider did not always foster a positive culture where people felt they could speak up and their voice would be heard. The provider had policies and processes to support staff with speaking up. This included guidance for staff on how to raise concerns, which staff could do anonymously. The provider told us they conducted staff surveys which were anonymous and staff returned completed surveys to the team leader. However, the provider had failed to consider team leaders would know who had completed anonymous surveys as staff returned the completed surveys in person. This meant the provider could not be assured staff felt able to raise concerns through this process. Staff told us they were aware of freedom to speak up. Staff told us leaders encouraged staff to speak up through “team meetings, staff supervisions and by promoting an open and supportive environment”. Staff told us when they raised concerns such as a safety issue, they were listened to and appropriate action was taken to resolve it. We reviewed minutes of staff meetings, and these did not show all staff had been included nor any questions and opinions were sought from staff.

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.

Staff told us they were treated fairly, respectfully and the service promoted equality and valued diversity among staff and people. Staff told us the provider upheld staff's human rights through policies, fair treatment and equal opportunities.

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 failed to operate systems effectively to identify shortfalls and regulatory compliance. For example, the provider had failed to identify care plans and risk assessments were not always accurate or person-centred. Additionally, the provider had failed to ensure they had accurate oversight of staff training, accidents and incidents. This meant the provider could not be assured they were consistently delivering safe, high quality care. To ensure we can perform our regulatory functions, providers are required to share relevant information with us. However, during this inspection, the provider failed to consistently respond to our requests for information, and we did not receive all the information we requested. It is a legal requirement for providers to display their most recent CQC rating. We identified the provider had failed to display their most recent rating on their website. The provider had failed to identify information contained on Medicines Administration Records (MARs) charts was clear. For example, where staff had completed an entry on MARs to show medicines had been administered, the registered manager was unsure what the entry stood for. The registered manager told us they would review this. Systems and processes did not identify staff were not always recruited safely. At our previous inspection in 2024, we identified breaches, including a breach of regulation in relation to good governance. At this inspection we found the provider had failed to act and make sufficient improvements. This meant systems for checking care quality and safety remained inconsistent and ineffective.

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 provider told us they worked with professionals such as the GP and district nurses. A professional told us when concerns had been raised, they found the registered manager to be responsive and proactive, with actions implemented to prevent further issues. Another professional told us when they were informed of concerns, the registered manager responded promptly, appropriately and engaged well. Staff told us they worked with healthcare professionals, relatives and the management supported staff in accessing these partnerships when needed.

The provider focussed on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff told us the provider involved people and relatives through regular feedback surveys, focus groups, and staff were supported to attend courses relevant to their development. Staff also told us time was allocated for learning and reflective practice which promoted a culture of continuous improvement and the service took their ideas and information into consideration.