Winners Trophy

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 registered service. This key question has been rated as inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance.

This service scored 36 (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.

We requested documents about the service strategy and business plans, but the provider did not send us any information. The registered manager told us they were not currently actively bidding for new packages of care to ensure they had the right balance of staff to service user ratio. In the future they were looking at developing a supported living service. However, when asked about the culture, most staff told us what the service was aiming to achieve for people. One staff member told us, “We are a friendly organisation that feels for the service users. What we want to see from them is that they're happy at the end of the day and we've given them the service that is in accordance with who they are as individuals.”

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. For example, we identified several concerns around safe care and treatment, needs for consent and governance during the inspection which the registered manager was responsible for, and which had not been identified prior to our inspection. The registered manager had completed a mental capacity assessment for a service user which was not in line with the mental capacity act guidelines and best practice. The registered manager had sometimes completed care visits to service users, and their lack of person-centred language used in daily notes was noted during the inspection. The registered manager also provided different information to that which was provided to us by staff, service users and relatives during the inspection and therefore we have concerns about the registered manager’s oversight of the service.

For example, a person had a live-in care package, and the registered manager told us, “Some staff go in 3 days a week, some for a whole week and some for 1 day so a rota is in place.” We asked whether the person with dementia found the transition between the changes of staff difficult and they told us, “No, not at all.” However, when we spoke with the live-in care worker they told us, “Other staff only cover when they go on annual leave so they are with the person most of the time,” and “[Person] finds it difficult when I go on annual leave and won’t do personal care or eat well, they get confused and think someone is in their house and stealing from them, staff regularly call me so I can talk to [Person] and calm them down.”

Despite our requests for information, the registered manager was not able to provide us with all the evidence requested within the time frame stipulated.

However, the registered manager was able to tell us basic information about their regulatory responsibility and their reporting duties. They told us about the different support they had accessed through the local authority and manager forums, and they had accessed training such as managing a care service, communication and social media. Staff told us leaders had good knowledge and were supportive. This was the first inspection of the service, and we found the registered manager and nominated individual positive and open to discussion about the improvements they needed to make. For example, after the inspection, the registered manager provided us with a copy of their action plan and told us, “As a registered manager, I take full responsibility for the shortfalls identified and am actively driving the action plan forward with accountability and transparency.”

The provider did not always foster a positive culture where people felt they could speak up and their voice would be heard. Some staff told us they had to ask for something more than once to ensure their voices were heard so changes could be made. One person told us about a complaint they made and how they felt the provider was, “defensive, rather than listening to their concerns.” There was a whistleblowing policy in place, but this focused on correctional and disciplinary action for staff rather than the freedom for people to speak up about any concerns without fear of retribution.

However, staff we spoke with knew how to speak up and contact external agencies such as CQC and the local authorities. One staff member told us, “I can speak my mind, no fear I might lose my job. I need to speak up when things aren’t right. I’m not afraid, I have the freedom to speak out and I know who to contact.”

There were policies and procedures in place to support workforce equality, diversity and inclusion. However, 2 polices, such as the service’s recruitment policy and its equal opportunities and anti-discrimination policy did not identify all the protected characteristics as outlined in the Equality Act 2010. The policies contained information such as, “Staff/workers, will only be discriminated between on the basis of their ability to perform their work to the required standards of professionalism, efficiency and safety.” The registered manager told us they would amend the policies in line with the Equality Act 2010.

However, most of the staff were working on a sponsorship licence from overseas and told us they had not experienced any discrimination towards them. They were positive about their experiences from an equality, diversity and inclusion perspective. Staff completed a health questionnaire when they commenced working with the service, so the provider was able to support staff if any reasonable adjustments needed to be made.

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.

Some of the service policies had not always been fully completed, and key information was missing from some. For example, the provider’s audit policy did not include details of how the service would conduct audits. Furthermore, the provider’s safeguarding policy did not have key contact details for local authorities, and its data protection policy did not refer to sensitive personal data, such as trade union membership, generic data and biometric data. Therefore, policies could not always be effectively followed by staff. We received conflicting information about whether an unpaid professional, who was also a family member of the registered manager, had access to people’s records. For example, we were told on one occasion the unpaid professional looked at care plans and risk assessments to provide support and guidance to the service. However, on another occasion we were told they looked at care plans and risk assessments, but people’s personal details were taken out before they were reviewed. Therefore, we were unsure if the General Data Protection Regulation (GDPR) had been breached by the service.

The provider’s systems and processes for auditing had not identified issues in a timely way and were not acted upon. This meant the audit systems for identifying, capturing and managing organisational risk and issues were ineffective in identifying concerns. The provider did not send through all the audits for the service as part of this inspection, and we did not receive any medicines audits so we could not be assured the concerns we found had been identified by the provider prior to our inspection. Whilst the provider gave us copies of the care plan and risk assessment audits, these were not consistently undertaken or were not effective in identifying the concerns we found during the inspection.

The systems and processes used to obtain consent and to assess for capacity and make decisions for service users did not ensure the service was working in line with national guidance and best practice.

The assessments to monitor and mitigate risks to the business were not effective. For example, the Business Continuity Plan (BCP) did not identify what initial actions should be taken in the event of an incident and did not address how the service would identify and prioritise people at high risk. Key emergency contact details were not available for internal and external stakeholders and although some areas of service disruption had been identified the relevant actions to take to manage those disruptions. However, the provider had not yet needed to implement their BCP due to an emergency situation.

The provider did not maintain oversight of staff training records and it was identified some staff had either not completed all required training or some staff details were missing from the training matrix. Some recruitment records relating to staff employed by the service was not in line with national legislation or in line with the provider’s policy. After we provided feedback to the provider about the findings of this inspection, they sent us through a copy of their action plan of all the changes they were going to make. For example, they said they were going to review all the policies where we had identified concerns and review all of the care plans according to best practice. They also included reference to conducting post-training supervision to see if staff understand what they have learned.

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. For example, a referral had not been placed with professionals for a person who lacked capacity and had restrictions in place. However, we found some referrals and communications had been made with partners on behalf of some people.

Partners who had worked with the provider gave us positive comments about the staff. For example, “We have never had any concerns raised about the staff who work for Winners Trophy, or anything negative about how people are treated,” and “I could always get in touch with them and [Manager] always responded quickly to emails.”

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. Systems and processes in place were not available to support learning, improvement and innovation. For example, there was there was no system available to record safeguarding concerns or service incidents, nor identify what actions were taken, to enable the service to monitor for any themes or trends.

Where people had raised complaints about the service, there was no system in place to record of these complaints and the actions and outcomes undertaken so no learning could be formalised. Some evidence of team meetings held was provided as part of this inspection, however, there was no process in place to share the contents of these with staff who could not attend to support their learning and effective team working. Some staff confirmed they had not received notes from team meetings if they were unable to attend. This meant some staff did not have up-to-date information about the organisation to be effective in their role. The registered manager told us, “They are learning a lot about managing this type of service as time goes on and it is ongoing.”