Deway Care 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 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.

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 gave positive feedback about the culture of the service. They felt well supported by their manager and colleagues. A member of staff said, “I am happy with working with deway they are lovely. I work with good people. I love the way they work as a team.”

The provider had inclusive leaders who understood the context in which they delivered care. Leaders had the skills, knowledge, experience and credibility to lead effectively. However, people felt there had been a change in the service following recruitment issues and they were not familiar with the managers of the service. A relative told us, “The office staff just don’t seem to be as good as previous staff.” A person said, “I don’t know of any of the managers names in the office.” However, another relative told us, “I speak with [staff] in the office, [they] visited at the beginning, and I speak with [them] on the phone. [Staff] always responds to things I ask for.”

The registered manager divided their time between here and their other services. They had a human resources manager to monitor staff recruitment and training, a care coordinator who did care plan reviews and staff competency assessments. There was an external consultant who provided quality assurance support. They were aware of the issues the service faced and were working towards resolving them.

The provider’s whilst blowing procedure was not clear. We requested their policy and received a flow chart; this did not include contact details for who staff could escalate concerns too. There was a poster in the office, and a manager told us the information was shared with staff via a messaging application. Staff were advised to take a picture of the details when they came in. If a staff member had a concern about the registered manager, they were advised to approach the Human Resources manager who would liaise with an external consultant.

Staff we spoke with understood their responsibilities around whistle blowing. A staff member said, “I report anything in the field, or about staff. Report to care coordinator or manager. To correct anything.” However, when we asked about who to escalate manager concerns to, they told us, “Not sure. Never had a concern with the manager. I have reported concerns about my colleagues.” Therefore, we were not assured the process to make staff aware was effective.

Following our visit, the provider shared their whistle blowing policy. We noted the guidance differed to what we had been told, but it did include external organisation contact details for staff to approach.

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.

They had policies to support equal opportunities and inclusion.

The provider’s processes to monitor the quality and safety of the service were not always effective. Staff audited people’s records, but these had not identified the issues we found related to missing risk assessments and issues with medicines administration documentation.

The provider had an electronic system to monitor people’s visit times. We reviewed daily logs and found some had missing entries. We fed this back to the registered manager, and they told as they had not had any missed visits. The system alerted the office if staff had not logged in to a visit to mitigate the risk of this. There was no documented audit of people’s visit times. This meant we did not see evidence of gaps identified and explained and it was unclear how it would be identified if people did not receive their full visit time.

The provider had not identified staff had not completed all training as required in their training matrix. Staff competency assessments had not identified any areas for staff to improve. We noted the narrative on these were identical, rather than showing individual responses, which would be a more robust demonstration of their understanding.

The provider had logs to monitor incidents, safeguarding concerns and complaints. People’s feedback suggested not all issues reported were included here. This meant there was a risk they were not investigated to identify learning to help prevent them happening again.

The registered manager told is they would review the issues we found. They said, “We will take everything back and improve.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The service did not have much involvement with other professionals. Staff reported concerns and where referrals to other services were required these tended to be arranged by their families.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The provider had a quality assurance plan with actions to improve the service. This mainly related to recruitment and included initial steps to be taken as well as a long-term plan to reduce use of agency staff. Other plans included more wellbeing/support for staff and gathering feedback from people and relatives via survey with concerns and suggestions to be addressed promptly.

The provider responded well to our findings following the inspection and they planned to review and address the issues we raised.