Advance Essex and East London

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 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.

During our assessment of this key question, we found concerns around the provider's systems and processes. We found a breach of the legal regulation to 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 Head of Operations recognised improvements were needed to ensure governance and leadership was more robust and effective in managing the day-to-day quality assurance of the service. This would ensure all actions identified in quality audits were followed through and sustainability was embedded into the service. The management team had clear values and were aware of the direction they wanted to take. The support manager had developed a listening culture where staff can feel they were available for them to talk to.

The registered manager was unavailable on the day of the assessment. There was a clear staffing structure in place with a support manager managing the day to day running of the service. The Head of Operations had oversight of the service in the registered manager’s absence and had acknowledged changes were required to make improvements to their service.

The support manager was clear about their roles and had the skills, knowledge and experience to perform their role. The support manager felt supported by the Head of Operations. However, we found limited evidence to show the registered manager had carried out robust audits or had processes in place. The audits carried out lacked detail and were mostly a tick box exercise. We were not assured the registered manager had good oversight of the service.

The service had policy and processes for staff to follow on ‘whistle blowing’. Staff meetings were being held regularly. We reviewed minutes and saw they included information about the service as well as reminders about training, staff rota’s, safeguarding and PPE. However, there were no action plans completed to evidence how issues raised were to be addressed, dates to be achieved and if actions had been resolved or remained outstanding.

The support manager held regular discussions with people to share their thoughts about how the service was performing and to discuss the support they received and if any improvements could be made. However, there was no formal record kept of these discussions.

The service had sent out recent surveys to people using the service to gather feedback about the service. The results were analysed for themes or trends to identify ways to improve the service.

Staff told us they had regular supervisions. A staff member told us “The support manager carries out regular supervision and we also have observations where they just turn up and observe us.” Staff told us they had an induction when they first started, and this helped them prepare for their role. Staff induction booklets were detailed and included shadowing shifts.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. There was a policy in place to protect staff from harassment and bullying and a focus on protected characteristics under the Equality Act.

The quality assurance and governance arrangements in place were not always effective in identifying shortfalls at the service. The audits carried out by the registered manager lacked detail and were mostly a tick box exercise and did not identify the shortfalls we found. This meant effective auditing arrangements were not in place to assess, monitor and improve the quality and safety of the service provided. Care plans, staff files and infection prevention and control were not being audited regularly. Staff meeting minutes did not include action plans completed to evidence how issues raised were to be addressed, dates to be achieved and if actions had been resolved or remained outstanding. The service had an improvement plan in place. A service improvement plan includes checklists and examples that help identify the necessary actions for enhancement and aid in developing an action plan to implement the required changes. However, not all actions identified on the plan had been achieved or completed. There was a lack of monitoring by the registered manager, who did not demonstrate appropriate management oversight of the service.

Effective systems to monitor and improve the quality of the service were not in place. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service 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 support manager had developed good links and worked closely with health professional. We requested information from partners however, we received no information in response to our request.

The management and staff shared the same goal to provide positive outcomes for people. The Head of Operations understood improvements were needed. The management encouraged staff to discuss and share ideas for improvement and innovation. The Head of Operations was passionate about making improvements in the service and told us, “I want to keep staff involved throughout this process.” The provider kept a formal record of lessons learnt and these were cascaded through to registered and support managers. However, the lessons learnt completed by the support manager following an audit, often lacked detail and did not include how improvements would be made or monitored for effectiveness.

The organisation was clear about their vision and values and were aware they had more work to do to ensure all processes were communicated clearly and embedded to support learning and innovation.