Mira Social Care

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 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 at the service.

This service scored 62 (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 fostered a positive and inclusive environment within the small, diverse team and encouraged staff to raise concerns openly. Ongoing discussions about safeguarding and professional expectations helped prevent negative cultures from developing and supported consistent, safe practice.

Staff, people and relatives benefited from the manager’s focus on learning, openness and maintaining a respectful culture. Staff said they felt supported, motivated and committed to helping people remain independent and engaged in daily life. This approach ensured the provider’s values were reflected in day‑to‑day care.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders were approachable, supportive and acted on concerns promptly. Leaders demonstrated compassion and skill, ensuring staff were competent and confident in their roles. The registered manager identified training needs through supervision and addressed gaps quickly, including arranging re‑testing where competency was insufficient and providing practical, hands‑on guidance.

Leaders promoted an inclusive and open culture within the small, diverse team. Staff were encouraged to speak openly, and expectations were reinforced through daily communication, safeguarding reminders and regular meetings. Leaders also showed flexibility and responsiveness to people’s changing needs, often adjusting visits or providing direct support when required. This helped ensure the service’s values were consistently embedded in day‑to‑day practice.

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

Staff felt able to raise concerns and speak openly, which supported an open and transparent culture. They told us they were confident discussing risks and escalating issues, and a whistleblowing policy was in place to guide safe reporting.

Staff said they felt valued, listened to and comfortable raising issues directly with the registered manager, who acted on concerns promptly. Relatives also described staff as approachable and responsive during visits, helping ensure concerns were shared quickly and addressed.

Leaders promoted openness and learning. Lessons from incidents were shared through handovers, meetings and day‑to‑day discussions, helping maintain positive teamwork and preventing problems from escalating

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 were treated fairly and reported being supported to work in ways that respected their individual circumstances. They told us the service was flexible when they needed adjustments, such as accommodating personal appointments or changes to the rota. Staff said they felt valued and had no concerns about how they or their colleagues were treated. They described leaders as approachable and responsive, and told us their human rights were upheld in the workplace. This meant staff experienced an inclusive culture where they felt listened to and supported to work safely and effectively.

The provider did not have effective governance arrangements to ensure safe, consistent or well‑led care, and leaders lacked reliable oversight of quality and risk.

Records were often inconsistent, outdated or contradictory, meaning leaders did not act on the best information about risk, performance or outcomes. Medicines information contained omissions and inaccuracies, several risk assessments lacked essential detail, including catheter care, environmental hazards and dementia‑related risks. Some documentation had not been updated to reflect people’s current needs.

Quality assurance systems were not effective. Audits were not routinely completed and had not identified gaps in care records, medicines management or environmental risk management. Policy governance was also weak; after unsubscribing from an external provider, required policies stopped being updated and there was no internal process to ensure documents remained current. Workforce governance showed similar failings, including a staff file with unexplained gaps in employment history, meaning required checks were not always fully completed or recorded.

These weaknesses meant leaders could not ensure safe practice or maintain reliable oversight of quality and risk, and the service was in was in breach of Regulation relating to good governance.

Following our feedback to the provider, some care records were updated to reflect people’s current needs. The provider also reported that they were in the process of implementing an electronic system to improve governance, enhance record accuracy and reduce the risk of recurrence.

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.

People benefited from the provider working with health and social care professionals. Staff had guidance from community nurses, GPs and a pharmacist to help meet people’s needs. This supported staff to provide person‑centred care that improved health and wellbeing.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider promoted continuous learning and improvement to enhance people’s experiences and outcomes. Staff received regular training, supervision and clear communication, which supported safe and timely care. Learning from incidents was used to strengthen practice and reduce risks. Staff were confident and adaptable, helping people stay safe, remain well and take part in community activities.

The service consistently used incident learning and staff feedback to improve day‑to‑day practice. The registered manager investigated incidents and implemented clear actions.

Supervision was used to identify training needs, and staff received additional development. The registered manager also provided hands on coaching in people’s homes to ensure new tasks were completed safely and in line with expectations.