Voyage (DCA) London East

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• 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 outstanding. 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.

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 clear vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding the needs of people and their communities. The organisation’s core values were embedded into the culture of the service through team meetings, staff supervision and observed practice.

The provider promoted an inclusive and supportive culture, ensuring people were involved in decisions about their care and that the focus remained on achieving the best possible outcomes for them.

The service did not have a manager registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. This service is required to have a registered manager, and the recently appointed manager told us it was their intention to apply to CQC to become the registered manager of the service.

We received mixed feedback about how the service was managed. Staff spoke positively about the manager, telling us they felt supported and believed the manager had the skills and knowledge to lead effectively. However, this view was not always shared by some families and professionals, who told us the service would benefit from stronger leadership and improved communication. The provider told us they supported new managers through leadership and communication training, and we received assurances this would help strengthen oversight and improve engagement with families and professionals.

The manager understood the context in which the provider delivered care and support and was familiar with the provider’s policies and processes. They demonstrated commitment to supporting people and improving their quality of life. We observed positive and respectful interactions between the manager, staff and people. People appeared comfortable and at ease in their company and were clearly familiar with their presence in the service.

The provider did not always ensure a culture where people, relatives and staff felt consistently listened to. Policies and procedures were in place to enable people, staff and visitors to provide feedback about their experiences of the service. Processes were available for people to raise concerns anonymously or with independent support, such as through advocacy services, families or wider support networks. However, some feedback indicated these processes were not always effective in ensuring people’s voices were fully heard or their views represented in a meaningful way. We sought and received assurances from the manager about the action being taken to address these concerns.

Staff were aware of the procedures for raising concerns both within the organisation and with partner agencies. They were encouraged to share ideas and reflect on practice through team meetings and one-to-one supervision. The provider promoted openness and learning, and feedback was used to inform and drive improvement within the service.

The provider valued diversity within the workforce and promoted an inclusive and fair culture. Policies and procedures supported equality, diversity and inclusion, and reflected relevant legislation and best practice guidance. Recruitment processes promoted fairness and ensured equal employment opportunities for all applicants.

Staff told us their individuality was respected and that they were treated fairly within the organisation. They described a positive and inclusive culture that recognised and celebrated diversity. Staff working on UK health and care worker visas told us they felt well supported, had good employment conditions and enjoyed working in the service.

The provider had systems to monitor quality, performance and risk; however, governance processes were not always effective in identifying and reporting shortfalls. Safeguarding concerns were raised but not always referred to the correct local authority, meaning the West Sussex Safeguarding Hub did not have full oversight of all incidents of concern. Some notifications were also submitted to CQC that did not meet the reporting criteria. The manager took immediate action to review and strengthen reporting systems to ensure future notifications will be accurate and comply with local authority and regulatory requirements.

The provider had clear responsibilities, roles, and systems of accountability to support governance processes. Regular quality assurance audits were undertaken, and actions were monitored to ensure improvements were made. There was evidence that recommendations from local authority monitoring visits had been implemented. Operational oversight of quality monitoring helped drive ongoing improvement within the service.

The provider worked in partnership with a range of organisations to support people’s health, wellbeing and inclusion in the community. Records showed that staff liaised with healthcare professionals and other relevant agencies to ensure people received appropriate and coordinated care. This collaborative approach helped to ensure people’s ongoing needs were assessed and met.

People accessed community facilities and healthcare services for routine checks and medical treatment. The manager engaged with local provider forums and network groups to share learning and good practice, which was cascaded to staff through meetings and supervisions. People were recognised within their local neighbourhoods, and we observed friendly and familiar interactions between people and members of the community.

The provider had processes and policies that promoted continuous learning, innovation and improvement across the organisation. However, feedback was mixed about how well these were embedded in practice. We received examples from professionals and people’s representatives where learning from incidents, assessments and feedback had not been consistently applied to drive positive outcomes for people. We sought and received assurances from the manager about the actions being taken to address these concerns and improve consistency.

The provider promoted a culture of openness and learning, and there was evidence the provider encouraged a culture of openness and learning from mistakes. The manager understood their responsibility to be transparent when things went wrong and shared learning with staff and people to support ongoing improvement.