Almag Healthcare Limited

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

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 legal regulation in relation to 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 were clear about the provider’s expectation of them and demonstrated the provider’s values in their day‑to‑day practice. A staff member said, “We promote person centred care by making sure people's needs are met and their routines and needs respected.”

The registered manager in discussions with us, acknowledged improvements were required to the service. They demonstrated a commitment to make these improvements and had taken some immediate actions to start this process.

The registered manager said, “I encourage staff to be open and honesty to enable any issues to be resolved. Care staff have care at the heart of everything they do. We aim to promote independence, provide person centred care and support people to remain in the community.”

Although the provider demonstrated an awareness of the context in which care, treatment and support were delivered, there were notable shortfalls in how effectively this understanding translated into the management of the service. While the provider possessed relevant skills, knowledge and experience, concerns remained about their ability to apply these consistently in practice.

Almag Healthcare Limited had been registered with the Care Quality Commission (CQC) since December 2022. During this time, the service had been dormant for less than 12 months and had previously provided care packages to people living in the south of the country. As an experienced provider, their systems, processes and procedures should have been robust, embedded and informed by previous learning. However, this was not reflected in the quality and reliability of the provider’s current practice.

The registered manager had not fulfilled their registration regulatory responsibilities of reporting all notifiable incidents as required. From reviewing people’s care records, we identified a person’s hospital acquired pressure sore had not been reported to CQC as required. This is important information that assists CQC in monitor services. Following the inspection, the registered manger submitted this information.

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

The provider had systems and processes, including policies and procedures such as freedom to speak up, whistleblowing and safeguarding to support staff to raise any concerns.

Staff felt confident speaking up when required. They told us they found the registered manager to be supportive and approachable, and they had regular contact with them. A staff member said, “I'm very happy working for the service and have no concerns. The manager has regular contact with us and is supportive and approachable.”

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 confirmed the registered manager was fair and treated them equally and they had not experienced any form of discrimination.

The registered manager told us and staff confirmed, reasonable adjustments were made to support staff in their role.

The provider had an equality and diversity policy that reflected the Equality Act 2010. This protected both staff and people using the service against any form of discrimination.

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’s lack of governance systems, processes and procedures, and oversight that assessed risks, and monitored quality and safety were either not implemented or sufficiently robust. The provider had failed to identify the shortfalls we found during this inspection. Whilst no person had come to harm, the shortfalls in governance and oversight put people at potential risk of harm.

For example, people’s pre‑assessment, care plans and risk assessments lacked detail and in places recorded no information and or was not reflective of people’s current care needs. This meant staff did not have the guidance they needed to understand people’s needs, preferences or risks, increasing the likelihood of inconsistent care, unmet needs and unsafe practice. The provider’s systems and processes had failed to identify these shortfalls.

Oversight and review procedures of people’s care lacked formal structure and consistency. Initial reviews were informal and not recorded. This meant there was no reliable process to ensure care plans were kept up to date, risks were regularly reviewed, or that changes in people’s needs were identified and acted upon in a timely way. There had been an over‑reliance on informal practice and a lack of robust record‑keeping, which limited the provider’s ability to monitor quality and drive improvement.

The provider’s medicines audit process had failed to identify all the shortfalls in best practice guidance identified in this inspection. Neither did it reflect the provider’s medicines policy.

A lack of systems and processes that monitored care call times effectively, complaints, incidents, accidents and safeguarding further contributed to a lack of governance and oversight impacting learning opportunities.

The provider’s systems and processes had failed to identify several shortfalls in recruitment procedures. For example, original staff identity documents had not been signed and dated to confirm they had been reviewed and verified. Staff interview records were incomplete, as interview questions and candidates’ responses were not stored in staff files. The registered manager assured us that interviews had taken place and later provided an example; however, this did not include the candidate’s responses and therefore did not demonstrate that interviews had been conducted as described. In addition, we did not see evidence that staff had completed a health questionnaire, meaning the provider could not demonstrate that staff were assessed as fit to work prior to employment.

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 gave examples of making referrals to external health and social care professionals for assessment, guidance and support when people’s needs changed and to improve people’s quality of life and outcomes. This included raising safety and wellbeing concerns.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The shortfalls in systems and processes reflected in this report demonstrated how improvements are required in leaning, improvement and innovation.

The registered manager told us they were in the process of recruiting an administrator to support them in managing the service. They were confident the additional role would enable them to have the opportunity to make the required improvements.

Whilst the registered manager told us they were aware of areas of the service that needed improving, they had not developed an action plan to prioritise actions and drive improvements. This meant we were not sufficiently assured that the provider had effective governance arrangements in place to identify, plan and monitor the improvements required. As a result, we could not be confident that the service had the necessary oversight or systems to ensure timely and sustained improvement.