Excel Care Management Services Ltd

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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 provider was in breach of regulations in relation to good governance of the service.

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 statement of purpose and a mission statement which outlined their commitment to supporting people with dignity and respect and providing individual choice and person-centred care, regardless of race, gender or culture.

The registered manager told us the vision for the service was to be the best and to treat people using the service with the same respect and dignity as ‘family members.’ The culture of the service was based on inclusion, engagement and diversity.

Most staff we spoke with told us the culture was positive. One staff member told us, “All the leaders are there for you; it is a good company.” However, a second staff member said, “It depends on who the staff are; some are listened to some aren’t. It’s very much them and us between carers and the office, as the office don’t know what it’s like being on calls. I have not had a problem because I speak up for myself.”

We did not see evidence of regular senior leadership meetings to review the vision for the service and developing strategic plans.

Leaders of the service had a wealth of experience within the care setting; however, the deputy manager and compliance lead were new to their roles within the service and there was a vacancy for a medicine’s coordinator role. This impacted on the registered manager’s capacity to lead effectively. We asked for an organisational diagram which highlighted key responsibilities and accountabilities for staff and there was nothing noted against the deputy manager’s role.

When we spoke with the registered manager about the key issues for the service, they did not outline most of the concerns which we had identified, including a lack of audits being completed, supervisions and spot checks not being regularly completed and omissions to care plans and risk assessments as a priority. Most concerns we identified during the assessment were not included on the providers’ action plan.

Most staff felt leaders were visible and approachable, were aware of any examples of poor culture and addressed any internal issues swiftly. A staff member told us, “If we get any feedback that is negative, we ensure we will rectify the issue. We aim for it [care provision] to be consistent.”

The provider had the relevant policies and procedures for ‘freedom to speak up’ including a whistleblowing policy and procedure which was also documented in the employment handbook.

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

Staff felt they could speak up and that their voice would be heard. One staff member told us “Staff can talk about concerns they may have to management, and they know it is a safe space and won’t be repeated.”

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. Leaders provided flexible working agreements to staff to account for personal circumstances such as caring responsibilities and health issues.

Leaders took active steps to ensure staff were representative of the population of people using the service. Leaders put reasonable adjustments in place for staff members to help them carry out their role. Staff told us all staff were treated equally by leaders. They did not feel there was a culture in which staff were discriminated against or bullied and provided examples of how the provider had supported them with flexible working arrangements when they had requested them.

We were not fully assured managers pro-actively engaged with staff with protected characteristics, via appropriate forums such as supervision and staff surveys, to ensure their voices were heard. However, most staff we spoke to were confident they could raise concerns directly with their leaders.

The provider’s systems and processes were not always effective. Staff spot checks, supervisions, and appraisals were not completed regularly, with little oversight. Care plans and risk assessments were not consistently updated, and a significant incident which had triggered the assessment had not been reported to CQC as required.

We were not assured the registered manager had oversight of the ECM system, including the amount of late calls and calls with no travel time (documented under the safe and effective quality statement). We requested policies and processes related to ECM usage but did not receive them.

Out-of-date medicines were found in the staff training room, stored unsafely. These were used for training purposes only, but the risk associated with this had not been identified by the provider. We requested their disposal.

The registered manager could not access staff training records due to system issues.

The registered manager did not complete regular service audits which contradicted the provider’s quality assurance policy.

There was no audit cycle to review trends, themes, or risks at a senior level. Although concerns were addressed individually, there was no structured review of incidents, safeguarding issues, or complaints, increasing the risk of recurring problems.

Policies and procedures were up to date. Staff were held accountable for poor conduct, and a data protection policy and business continuity plan were in place.

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. It was evident there was a good relationship with the local authority and good engagement during the service improvement plan process.

There was evidence of wellness checks being completed with staff; however, the most recent ones were completed in August 2024. There were only 3 – 4 responses from staff and no further wellbeing checks or responses since then. Staff wellness checks were not reviewed thematically.

We reviewed staff surveys from 2024. We saw that 8 had been completed by staff at various times of the year. Various surveys had no names on them, and some had no dates on them. We saw mixed feedback from the surveys; there was little evidence of how negative responses were followed up, acted upon or how the data was used in a collective, thematic way to better understand the service.

We saw evidence of 2 feedback forms from external services from 2024. We did not see evidence of what was done with this information. The local authority had completed a staff survey in July 2024; compliance with the survey recorded 16 responses being provided. Results from the survey were positive. We did not see evidence of how the registered manager used this survey to form a better understanding of the service.

We reviewed 2 surveys which had been sent to people in January 2025. We identified negative feedback had been provided by 1 person who completed a survey but did not see evidence of this being followed up. Most people and relatives we spoke to said they had not been contacted to provide their views on the service via a questionnaire, survey, or phone call; those that did recall this happening, told us that no improvements had been made following such contact.

We were not assured leaders had a good understanding of how to make improvements happen. Despite being part of a service improvement plan with the local authority recently, we found various aspects of the service still required improvement.

The providers’ action plan document was not detailed and did not identify the primary areas which needed to be addressed, nor did it outline which staff were responsible for the actions identified, or a date as to when the actions would be achieved.

We did not see evidence there was a consistent culture of learning from incidents or complaints. We were not assured there was a robust process for sharing learning from incidents and accidents and complaints, apart from ad hoc messages sent on WhatsApp groups to staff. One staff member told us, “I’m not sure if there are staff meetings but I haven’t been to any and as far as I am aware they [managers] don’t ask for people’s ideas for improvement.”