suite B, 1st Floor Shaw House 2-3 Tunsgate Guildford Surrey GU1 3QT Also known as Office

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 service was in breach of 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 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.
The registered manager told us how they met with staff on shift every day. These daily huddles were used to discuss people’s care, deliver training, discuss policies and engage in staff wellbeing.
We discussed shared direction with staff during feedback. Staff told us, “It is to make sure we provide the best care to a person to meet their needs. We must make sure we are providing person centred care because it is all about them, not us.” People also told us about their positive? experiences communicating with office staff. One person said, “The office staff are as caring as the care staff.”
 

Not all leaders understood the context in which the provider delivered care, treatment and support.
We received mixed feedback from staff. One staff said, “I did not feel the support from management, I felt like I was made to handle all the tasks on my own.” However, another staff said, “It is a well-managed service. It is structured in such a way that those in the office know what is going on. They are connected to what is going on in the field and therefore understand the nature of the work and at times, how unpredictable it is.” This meant not all staff felt supported, and managers led the service effectively.
The provider did not evidence leadership staff who were completing competency assessments were appropriately trained and skilled to do so. This demonstrated the provider did not always ensure leaders had the right skills, knowledge and credibility to lead effectively with training and assessments.
The provider demonstrated they completed supervisions with staff, and this included discussion of the staff’s wellbeing.

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

Staff told us, “The communication is so good. Our calls to the office [are] answered and I feel I am being heard and seen in this way.”

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 how the provider empowered and supported them to maintain their cultural and religious needs. One staff said, “There is huge sensitivity to the cultural and religious needs of the staff.”
 

The provider did not maintain effective oversight and good governance of the service.
The provider had not identified all shortfalls as part of their auditing processes. This meant quality assurance systems were not always effective and demonstrated all areas of risk to people had been mitigated. The provider did not ensure they maintained an accurate, complete and contemporaneous record in respect of each service user with regard to complaints.
The registered manager did not ensure medicines audits were always effective . For example, these audits had failed to identify concerns we found with PRN protocols and variable dosing of medicines. Recruitment practices were not in line with legislation. The provider failed to identify some tasks which staff were completing were not competency assessed before care was provided. The provider also failed to evidence that staff completing the assessor tasks had been appropriately assessed as competent to do so. Lack of competency assessments for all tasks meant staff did not always have the necessary skills or knowledge to deliver safe care, placing people at risk of harm.
The registered manager had failed to maintain oversight of all safeguarding concerns found in people’s care records. Where any form of abuse is suspected, occurs, is discovered, or reported by a third party, the provider must take appropriate action without delay. The action they must take includes investigation and/or referral to the appropriate agency. We found examples where these concerns were identified but were not reported without delay to appropriate authorities.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.
We found some examples where referrals were made to district nurses and occupational therapists. However, we found the provider did not work in partnership with safeguarding agencies. This did not demonstrate the provider always understood their duty and responsibility in raising referrals and concerns about people’s care and wellbeing. This also meant there was a lack of information sharing and learning with partners to collaborate for improvement.
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.
We found the provider completed surveys and feedback calls with people and relatives using the service. However, there was no route cause analysis completed for each incident and complaint to establish learning outcomes. This meant continuous improvement and innovation was not always demonstrated. Moreover, it was not evidenced how learning and improvement outcomes were always shared with all staff within the service to minimise the risk of incidents reoccurring.