CREATIVE CARE HOME 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 – 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 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. There was a breach of the regulation good governance.

This service scored 54 (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 clear shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They understood the challenges and the needs of people and their communities.

The culture of the service was warm, open and transparent. People and relatives were positive about support and the staff team. The provider demonstrated a passion for providing good quality care. Staff told us the provider was supportive and approachable.

The provider acknowledged during discussions that some areas of the service required improvement and further development. They responded positively to CQC feedback demonstrating a clear commitment to ensuring the culture and delivery of the service met regulatory requirements.

The provider had an inclusive leader, but they did not always understand the context in which they delivered care, treatment and support. Improvement in the management and leadership of the service were required.

The quality assurance systems specified in the provider’s policies and procedures had not been implemented for the provider to be assured people’s care mitigated risks to their health and welfare. There were no checks on the assessment, care planning and review process, the management of medicines, staff training or governance. This did not demonstrate the provider fully understood the regulatory context in which they delivered care, treatment and support.

The provider and registered manager demonstrated a caring and compassionate approach to people’s care and the people they cared for. Leaders and staff were knowledgeable about people’s day to day needs and spoke warmly about the people they cared for with genuine affection. Staff told us they felt supported and received supervision from the manager. Comments included, “[Name of manager] is “wonderful.”

People felt they could speak up and that their voice would be heard.

People, relatives and staff felt able to speak up about any concerns and felt they would be listened to. People were happy with the care they received and had no concerns.

Safeguarding and whistleblowing policies were in place to guide staff on how to speak up about safeguarding or other concerns.

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 felt valued by the provider and treated fairly. The provider had policies and procedures in place to promote workforce equality, diversity and inclusion. This included ensuring staff with protected characteristics under the Equality Act 2010 had equal opportunity and equity in recruitment and employment.

The provider did not operate robust systems of accountability and good governance. They did not adequately monitor the quality and safety of the service to identify where improvements to quality and safety were required.

The provider did not have appropriate systems in place to monitor and address shortfalls in assessment, care planning, risk management, medicines and governance. There were gaps in the knowledge of the provider and registered manager with regards to the health and social care regulations and best practice guidance which impacted on the overall quality and safety of service delivery.

No care plan audits were undertaken to ensure staff had accurate and adequate information and guidance on people’s needs and risks. Care plans lacked key information to enable staff to provide safe and effective care as robust risk assessments had not been completed. Accurate and contemporaneous records in relation to people’s care were not maintained at all times. The systems in place to monitor and ensure people’s care was reviewed were not effective.

The management of medicines did not adhere to best practice guidance. There were no robust systems in place to ensure the management of medicines was safe. There were no routine audits or stock checks on people’s medicines to ensure medicines were given correctly. Records maintained in relation to medicines were poorly maintained and no action had been taken to address this.

The completion of staff training and the quality of the staff induction was not reviewed appropriately to ensure staff employed had the necessary skills, experience and knowledge prior to working unsupervised with people. This placed people at risk of poor quality care.

The provider had a variety of policies and procedures in place to guide the assessment, planning and delivery of care but these were not always appropriate or followed.For example, some policies referred to a registered manager no longer in post or contained guidance not applicable to a domiciliary care service. Policies such as the provider’s assessment and support planning policy, medicines policies, staff recruitment, selection and training policy and policies related to quality assurance and governance were not followed. The systems in place to ensure these were followed was not effective.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They did have not however have adequate systems in place to learn or share robust information about the service with partners to collaborate for improvement.

Records in relation to people’s needs and care were not always up to date or sufficiently detailed to share robust information about the service and the care people received with partners. For example, visit records had not always been completed consistently to record the care people had received and to enable clear tracking of the person’s well being to share with other professionals.

Feedback from other professionals involved in people’s care was positive. A visiting professional told us the provider collaborated with them well and had no concerns about the quality of care the person received. People told us their visits were regular and on time and it was clear people felt their support worked seamlessly.

The provider had some processes in place to share learning and improvements across the organisation. These systems were not effective and did not demonstrate a focus on continuous learning or that robust action was taken to drive up improvements.

The provider ensured spot checks on staff practice and staff supervision took place to share learning and identify any improvements in the support provided. There was however a lack of other effective systems in place to identify shortfalls in the service to drive up learning and improvement. The provider’s quality assurance and governance policies had not been implemented and there were no robust audits and checks in place to identify learning or to drive improvement.

The outcome of CQC’s assessment was discussed with the provider. They were open and receptive to feedback. They demonstrated a commitment to improving the service.