UKG Care Havant

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 good. At this assessment the rating has changed to requires improvement. This meant the leaders worked to create a culture that supported person-centred care. However, governance systems did not always effectively drive improvement’

The service was in breach of legal regulation in relation to records and poor governance at the service.

This service scored 61 (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.

Staff knew the aims and values of the organisation and senior staff told us they went through the values of the service as part of the induction for new staff, and during training and supervisions.

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. At the time of the inspection the registered manager was away from the office and the provider was leading the inspection. Senior staff supported the provider with the running of the service. Staff we spoke with felt supported by the provider and senior team.

However, we identified a breach of legal regulations and concerns relating to records and governance. Leaders had not independently identified or acted on these issues prior to our assessment. We also found inconsistencies in the provider and senior teams understanding of records and assessments, including those related to environmental risks and medicine management. This meant some development was needed in their skills and knowledge to lead effectively. Improvements were already underway and that some monitoring systems existed but required stronger documentation.

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

The provider sent out surveys to people and their relatives to gain their views, this was then used to make improvements to the service.

The provider had appropriate polices in place as well as a policy on Duty of Candour to ensure staff acted in an open and transparent way in relation to care and treatment if people came to harm.

Staff we spoke with were happy to speak up for people and were always listening to people’s needs and act on any concerns or needs that people may have. Staff we spoke with were aware of how to raise concerns.

The provider told us, “I think we are very open were not a blame company. It’s all about learning if things happen let’s have a look and see what we could have done in a different way.”

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.

Policies and procedures to promote diversity and equality were in place. Senior management engaged with staff regularly to gain their feedback and support them with their individual needs and circumstances. We saw records following a staff survey where action was needed regarding communication amongst staff, with plans in place for ongoing improvements. The provider told us how they have worked with staff in reducing hours to support them, looking at what they can do and can’t do and then adapting their rotas around their family life.

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.

Improvements in records relating to people’s care and the management of the service were needed. The provider was unable to provide us with all the information requested. This included service improvement plans, copies of audits for care plans and monitoring the service as part of their governance procedures. Records needed improvements including environmental and risk assessment records, complaints and incidents. While these had been updated following the inspection the provider did not pick up these concerns which put people at risk of harm.

The provider also needed to ensure their auditing processes were clearly documented and effective in promoting safety and good quality care. No records were provided to evidence the provider and registered manager’s audit process. The only audits provided by the provider during the inspection related to medicines. However, we had concerns about the accuracy and effectiveness of these audits. For example, they did not identify no PRN records were in place to support some people to manage their medicines safely. The internal monitoring of risk and safety were not sufficiently robust or effective in identifying and addressing areas for improvement. Therefore, the shortfalls we found had not been identified prior to our inspections. The provider took action during the inspection to start addressing the shortfalls.

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.

Records showed the leadership team and staff worked effectively with health and social care professionals to meet people’s needs. Staff had undertaken reviews with relevant healthcare professionals as people’s needs had increased and made referrals to occupational therapists, community nurses and GPs when needed.

The provider told us how they had supported people using the service to be part of the community. For example, signposting people to local knitting groups, age concern and the local church for activities.

The provider and senior team were motivated to work towards continuous learning and improvement across the organisation. Although the provider was motivated to learn and improve the service for people, their overall ambition was limited by the lack of established risk and quality monitoring systems. This meant they might not always be aware of shortfalls to enable prompt improvement and learning. However, they were quick to respond to any shortfalls we found during the inspection and started to make improvements.

The provider was motivated to learn and had started to improve the service during our inspection for people. The lack of established risk and quality monitoring systems meant they might not always be aware of shortfalls to enable prompt improvement and learning.