Utopia Care Limited - Thurrock Branch

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.

During our assessment of this key question, we identified a breach of the legal regulation in relation to good governance. This was because we found concerns around the effectiveness of the provider's quality assurance and oversight systems and processes.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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. The registered manager recognised improvements were needed to ensure governance and leadership was more robust and effective in managing the day-to-day monitoring and assessment of the quality of the service and to ensure it was always safe and met people’s needs. They had not always ensured all actions identified in quality audits were followed through and sustainability was embedded into the service.

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.

There was a clear staffing structure in place with a care manager and 2 care coordinators managing the day to day running of the service. The registered manager had appointed a care manager who was implementing change. The registered manager acknowledged changes were required to make improvements to their service.

The service had policy and processes for staff to follow on ‘whistle blowing’. The registered manager had developed a listening culture where staff felt they were available for them to talk to. This meant staff felt supported, valued and confident to raise concerns or seek guidance, which contributed to a positive working environment.

Staff told us they had regular supervisions. A staff member told us “The care manager carries out regular supervision and we also have observations where they just turn up and observe us.” Another staff member told us, “I had a spot check carried out last week. The manager just turned up. It is helpful for us as staff to know management are observing us and this also gives us an opportunity to discuss any concerns we may have. I would have no problem talking to the management if I had to discuss something with them.”

There was a policy in place to protect staff from harassment and bullying and a focus on protected characteristics under the Equality Act.

The registered manager had developed an inclusive workforce and recognized the value of diversity amongst the team.

The quality assurance and governance arrangements in place were not always effective in identifying shortfalls at the service. The audits carried out by the care manager lacked detail and were mostly a tick box exercise and did not identify the shortfalls we found. This meant effective auditing arrangements were not in place to assess, monitor and improve the quality and safety of the service provided. Care plans and staff files were not being audited regularly. Staff meeting minutes did not include action plans completed to evidence how issues raised were to be addressed, dates to be achieved and if actions had been resolved or remained outstanding. There was a lack of monitoring by the registered manager, who did not demonstrate appropriate management oversight of the service.

The service 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. The management had developed good links and worked closely with health professionals. However, people’s care plans did not contain information about involvement with other professionals.

We received positive feedback from a healthcare professional. They told us, “Over the last few months, it does feel like the provider goes through periods of having increased complaints and concerns bought to our attention, mixed with periods where complaints and safeguarding concerns are at a minimum. The service had a registered manager, while the care manager is currently awaiting their CQC registration to replace them. At this time, we believe the current manager will manage another branch of the service and will continue to support and advise where needed going forward. Both of these managers are approachable, honest, and have kept in frequent communication with us.”

The service 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.

The registered manager understood improvements were needed. The management encouraged staff to discuss and share ideas for improvement and innovation. The registered manager was passionate about making improvements in the service and told us, “I want to keep staff involved throughout this process.” Management kept a formal record of lessons learnt and these were cascaded through to the care manager and care coordinators. However, the lessons learnt completed by the management following audits, often lacked detail and did not include how improvements would be made or monitored for effectiveness.

The organisation was clear about their vision and values and were aware they had more work to do to ensure all processes were communicated clearly and embedded to support learning and innovation.