24/7 Divine Healthcare 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. This is the first assessment for this newly 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.

The service was in breach of legal regulation in relation to 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 developed an inclusive culture at the service. People and their relatives were positive about how the service was run and the support they received from the NI and care workers. The NI demonstrated a willingness to make improvements in relation to the concerns we found at the inspection.

The service had inclusive leaders. One relative told us, “The NI is a good manager because they have empathy. They contact me weekly as they are concerned about both me and my loved ones. I can call them at any time even in the early hours of the morning; they are like a family.” Care workers gave us positive feedback about the nominated individual and told us they had access to support and advice from the nominated individual and that they were approachable. However, the provider did not always demonstrate the skills, and knowledge to effectively manage the service and respond to concerns we found in a timely way. For example, the NI did not have a clear plan for the service improvement, when we asked about actions, they had taken to improve the quality and safety of the services people received. The NI told us they are still trying to recover from the ‘crisis’ that had taken place a year before this inspection and very little had been achieved since.

The provider had systems and process for people, relatives, and care workers to speak up and share their concerns. Care workers were aware of these and told us they felt confident speaking with the nominated individual if required.

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 employed care workers of both the genders to meet people’s preferences of a care worker for delivering personal care to them.

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.

The quality assurance systems that were in place to assess and monitor the quality and safety of the service and to assess, monitor and mitigate risks to the health safety and welfare of people were not effectively implemented, operated and managed. For example, there were no risk mitigation plan with guidance for staff about risk to self-harm, cutting and using a ligature, risks to staff including unfounded allegations and people’s complex communication needs.

The provider failed to work in line with the principles of the Mental Capacity Act (MCA) 2005 and associated code of practice before delivering a regulated activity. The provider failed to provide care delivery records for 2 people to show how they met people’s needs. The provider failed to reflect in people’s hospital passport what reasonable adjustments were in place to meet their communication, emotional, behavioural, and health needs. The provider failed to have an effective system and processes to carry out pre-employment recruitment checks for care workers. The provider failed to have effective systems and process for administration of medicines, to ensure people have received their prescribed medicines safely at all times.

The provider, despite having an additional condition on their registration, continued to provide personal care in a specialist service to people whose presenting need for care or support is as a direct result of the person’s learning disability and or autism.

The NI was committed to working in partnership with external professionals to achieve positive outcome for people. They worked closely with local authority colleagues and a range of healthcare professionals.

The systems and processes for learning and making improvements were not effective. In response to our feedback, the NI told us how they have planned to make improvements. However, we were not provided with an improvement plan to show how and by when they planned to make improvements.