Areys Care

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

Well-led – this means evidence was sought that leadership, management and governance assured high-quality, person-centred care and promoted an open, fair culture. This was the first assessment since the service registered with CQC on 29 May 2023. This key question has been rated Requires Improvement. The provider was in breach of legal regulations in relation to good governance.

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.

This service scored 54 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Staff described the culture as positive and open. They said managers were approachable and available for support. Staff felt able to speak up and raise issues with managers. Although staff gave positive feedback about the culture, leaders had not fully embedded this through consistent oversight, learning and quality assurance. For example, they did not consistently analyse incidents, complaints and concerns to identify patterns or learning. This meant opportunities to reduce repeat issues and improve practice were missed.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Managers were responsive and easy to contact. However, they did not provide enough oversight to make sure care was safe and consistent. They did not always monitor care plans, risk assessments, medicines records, staff training records effectively. This meant leaders could not always show that they managed quality and safety well.

People did not always feel they could speak up and that their voice would be heard.

Staff told us they felt able to raise concerns with managers. They said they could speak to the manager directly and contact senior staff by phone or message. However, the provider did not have a clear or consistent system to record, review and act on these concerns. Provider relied mainly on informal conversations and messages. They could not always show what concerns staff had raised, what action they had taken, or how they used this information to improve the service.

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.

Diversity was valued and respected. It was described by staff that people’s cultural and language needs were accommodated, and that staff were supported with their own individual needs. One staff member said, “Yes, the service is respectful and supportive of my needs and makes adjustments when possible.”

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.

People were at risk of unsafe and inconsistent care. Staff did not always have clear or up-to-date information about people’s needs, choices and risks. This meant people may not receive safe or personalised support.

The provider did not oversee the service effectively. Checks focused too much on tasks and records. They did not show whether people received safe, good quality care.

Manager did not always act when they found problems. They did not make sure improvements happened or continued.

Care plans, risk assessments and medicines records were not always accurate or current. Records did not always match. This left staff without clear guidance on how to support people safely.

The provider did not use audits, incidents, complaints and concerns well. Manager did not identify repeated risks or learning. They did not always complete actions or check if changes improved care. This placed people at continued risk.

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.

Partnership working was seen through contact with stakeholders and responsive communication. Feedback from a local authority was positive about the care and support provided with flexibility and professionalism. The service was in the process of developing wider partnership links.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Leaders did not always show how they used quality checks to learn and improve the service. The provider had quality assurance systems, but these did not always identify concerns, lead to clear action plans, or show that improvements had been made. Managers did not consistently record how they reviewed issues, agreed actions, followed these up, or checked whether changes had improved people’s care. This meant the provider could not show that learning was fully embedded or that governance systems were driving continuous improvement.