Pronsahe Health Care

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 provider was in breach of legal regulation in relation to good governance.

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 told us how they enjoyed working for the service and that they always felt supported. The manager worked alongside staff on care calls when needed.

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.

Feedback from staff and people clearly showed that the registered manager was compassionate and put the care of people and the support of staff at the forefront of their role. However, shortfalls in the systems and processes we viewed demonstrated that there were areas for improvement in the management and governance. For example, regular audits had not taken place to ensure policies were up to date or recruitment procedures were effective and safe. Despite this the registered manager had been proactive in driving improvements across the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager regularly requested client feedback, they requested feedback to see if people were happy with their care and if they had any concerns. Staff told us they could speak to the manager if they had any concerns. There was a whistle blowing policy in place.

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 had specific training for equality, diversity and inclusion. Staff had flexibility with their shifts if they needed.

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 registered manager did not always have appropriate systems of quality monitoring and governance. Concerns were found at inspection and had not been identified or acted upon. We did not see systems of quality monitoring or governance in place at our inspection. For example, some policies and procedures were out of date or not available on the day. Training certificates were out of date. There were not effective systems in place to ensure that audits were carried out and policies and procedures were kept updated. This posed risk to people’s care and support. If risks had not been properly identified, or people’s training and skills were not meeting requirements for them to carry out their responsibilities safely, people were at risk of potential harm. However, since the inspection the registered manager had been proactive in updating policies, procedures and driving better compliance.

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 registered manager told us how they liaised with the GP, to discuss any changes in people’s health needs. We saw evidence of effective communication between community professionals detailed in people’s care plans.

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. They did not always ensure staff were appropriately skilled and competent to deliver safe care.

Improvements were identified in the induction, learning and development of staff. For example, the provider hadn’t ensured that staff were competent with certain tasks, and this needed to be overseen by an individual with the correct skill set to be able to effectively sign off their competency training and practices. Ongoing improvements were being implemented but were not fully embedded. However, staff spoke positively about the ongoing training and learning opportunities that were available to them. Staff told us, "Yes the management are approachable, they provide guidance when needed and provide us with ongoing training."