Archived: Achievers Care Solutions Limited

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• 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 was the provider’s first inspection at their new location. At our last inspection we rated this key question Inadequate. At this assessment, the rating has remained Inadequate.

This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The registered manager did not assure the delivery of high-quality care. The service was in breach of legal regulations in relation tothe governance of the service. There was a lack of understanding on how to meet the RSRCRC principles. Quality governance systems were not effective in their use and there was a lack of processes in place to gain feedback to drive improvement. There was a lack of robust oversight and lack of assurance processes.

This service scored 25 (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 failed to ensure effective oversight and leadership of the service. There was a lack of robust systems and processes in place to share and drive improvements in the service. The provider did not demonstrate an understanding of the challenges the service faced and had failed to make improvements since our last inspection.

Staff spoke positively about the registered manager and said she was supportive and approachable. However, we found the provider did not have robust systems in place to capture the views of staff. There was no evidence the provider demonstrated how they listen and respond to staff when concerns are raised.

The registered manager did not have an adequate understanding of their role and lacked oversight of the service. The registered manager did not provide evidence to demonstrate how the service was well led. The lack of systems to monitor the quality of the service and provide effective managerial oversight did not allow for lessons to be learnt. There was no evidence actions was taken to drive improvements in the service. This placed people at risk of harm. This demonstrated a continued breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There were no systems in place to support open and transparent ways of working. Although the service had policies in place, there were no systems to formally capture the views of staff. The provider was unable to demonstrate how they listen and respond to staff when concerns are raised.

The provider had policies in place to for recruitment, induction and training for staff however the provider was unable to demonstrate these processes were followed. The provider did not have organisational processes to follow to identify and address concerns with staff's working environment or access to development opportunities.

The recruitment policy was not followed meaning staff were not recruited safely. Records showed staff did not receive regular supervisions and not all staff were not up to date with training. Staff performance was not assessed or monitored and staff meetings were not recorded. This was a continued breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found systematic and widespread failings in the management of the service, which meant service users did not always receive safe care. The provider did not have effective systems and processes in place that enabled them to identify, monitor and assess risks to the health, safety and welfare of the people who use the service. Where risks had been identified, measures had not been introduced to remove the risk. For example, records of care were not complete and quality assurance systems were not effective. Audits had not been completed, showing a lack of effective quality assurance systems in place, but no actions had been implemented to address the concern and mitigate the risk. Audits failed to provide oversight of the service or identify areas of concern and drive improvement. This meant the provider had failed to monitor the progress of the service or improve the quality of care.

Providers have a statutory obligation to submit notifications to the CQC regarding specific incidents, including any police involvement related to the service. During our assessment we found the provider had failed to notify us of a police incident and despite our identification of this issue, they had still not submitted the required notification at the time of writing this report.

This was a continued breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider did not evidence continuous learning within the service. Quality assurance systems did not support consistent improvement. We found feedback from our previous inspection had not led to improvement to governance systems during this inspection. Audits to monitor the quality of the service were not completed.

There were systemic failings at the service and we continued to find multiple breaches. Concerns raised during the previous inspection had not been effectively addressed. There was no evidence of learning and innovation across the organisation and there was a significant lack of oversight and monitoring of the service by management. During this inspection, we found continuous breaches of regulation in relation to safe care and treatment, person centred care, need for consent, staffing, and governance. This placed people at risk of harm. This was a continued breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.