South East Focus 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 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 good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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.

Staff told us leaders promoted a positive culture of learning and development at the service. They said they felt listened too, valued and there were opportunities to develop their professional skills. The leadership team were a visual presence to people and staff. They took an active role in working alongside staff. This helped to ensure they understood people’s needs and the complexity of their care. The registered manager and nominated individual told us they wanted leaders to model good behaviour, respect staff and do their best to provide high quality care. Leaders promoted a no blame culture, where they encouraged staff to be reflective about their practice and open to feedback about how they could improve. Staff were aligned with the provider’s values and were consistently positive and enthusiastic about their roles. They told us they were afforded frequent opportunities to give feedback and leaders were open to their suggestions about how to improve the quality of care.

The provider had inclusive leaders at all levels who had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager understood their regulatory responsibilities. They were experienced, suitably qualified and knowledgeable. They had completed further qualifications relevant to their role. This included qualifications in leadership in health and social care and courses enabling them to deliver training to staff.

The nominated individual was involved in the day to day running of the service. They had experience in commissioning care services and had completed qualifications around mentoring staff. They had adapted principles from this training to promote a positive learning culture at the service.

Leaders had good accountability and clear responsibilities in their respective roles. Senior staff had a very good knowledge around how to implement best practice guidance into everyday policies and procedures. This included guidance around safeguarding, MCA and medicines. Senior staff were extremely motivated in their role and provided effective support to the registered manager in overseeing the quality and safety of the service. This helped to promote effective working practices and oversight of the service.

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

Staff told us they felt confident that they could raise any issues with the leaders, and they would be taken seriously and investigated. The provider had a whistle blowing policy in place, which detailed how staff could speak up about any concerns they had about the service. In addition, leaders were regularly in contact with staff through working alongside them, supervision, spot checks and team meetings. This helped to promote an open rapport and effective working relationships.

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.

The provider had policies and procedures in place around workforce equality and diversity. The leadership team were sensitive and responsive to staff’s individual circumstances. This helped to ensure reasonable adjustments were made to accommodate staff’s needs. The provider sought feedback from staff through supervisions, team meetings and appraisals. They analysed themes from feedback gained to evaluate if their systems to support staff were effective. The feedback the provider received reflected what staff told us about being well supported and valued in their role.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care and support

There were effective systems in place to oversee the quality and safety of the service. This included live monitoring of care through the electronic care planning system. This helped to ensure was carried out as planned. Senior staff completed more in-depth and reflective audits to identify trends, areas of strength and opportunities to make improvements. This included audits of care plans, care notes, medicines administration records. Senior staff also analysed findings from staff engagement through observation, supervision and competency assessments. Feedback from any learning identified was shared with staff through individual or group settings. For example, in May 2025, senior staff shared feedback with staff to improve systems around supporting people to renew their prescriptions. This helped to reduce the risks around people running out of their medicines.

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.

Leaders engaged with partners to share learning and good practice which promoted improvements in the quality of care. For example, leaders were part of a local network of independent domiciliary care providers. They had used feedback from other providers to identify alternative electronic care planning systems, which provided a greater level of functionality which they required. The registered manager had set up a series of trials of potential electronic systems. They had engaged with staff to identify the desired functions of any potential system. This enabled them to focus their enquiries where there was most practical value and relevance to the service.

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

Leaders were constantly looking for ways to improve the quality of care. The provider had an ongoing service improvement plan. This was developed using findings from audits, feedback from staff, people and stakeholders. Leaders regularly reviewed how effective the identified measures were in improving the quality of care. For example, the provider had developed a standard operating procedure to promote the safe and effective transfer of information between stakeholders when people moved between services, such as during hospital discharge. This helped to ensure staff followed a clear protocol and completed key actions before care recommenced. This helped to reduce risk related to failed hospital discharge.

The provider had applied to CQC to add the service specialism, learning disabilities. This application was in progress at the time of our inspection. The registered manager told us they had commissioned specialist training in this area for staff in preparation for this application. They told us that if the application was successful, they wished to diversify the services the provider offered to include supported living.