Firstcall 247 Limited (Gloucestershire)

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

The service was in breach of legal regulation in relation to the governance at the service.
 

This service scored 68 (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 and their communities.

Staff shared positive feedback in relation to their morale and the management of the service. They told us they felt supported by the management team and noticed an improving culture across the service, which focused on the wellbeing of both people receiving care and staff. They said there was an improved commitment to staff wellbeing and welfare. One staff member said, “Management are always helpful. The changes have been very positive. We have a very good team here and it is a very good place to work.” People and their relatives mainly commented positively and felt the service was gradually improving under the new management team. Effective business continuity and continuous improvement plans were in place, which provided managers with a structured approach to driving improvements and sustaining good practice.
 

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.

Whilst the registered manager and supporting management team were passionate about the service and driving improvement; we were not fully assured the team fully understood the provider’s regulatory requirements to sustain a safe and effective service.

The registered manager was newly appointed and divided their time between this service and another of the provider’s registered services. They had started to develop their knowledge and understanding of the service and had begun to introduce good practices.

The registered manager was receptive to our feedback provided during the assessment and demonstrated a commitment to improvement. However, additional time was required to ensure improvements were fully embedded and sustained in practice over the longer term.
 

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

The provider had a designated ‘Freedom to Speak Up’ lead to support staff and help them raise concerns in a safe environment. The provider was considering providing the lead with higher level of whistleblowing training to further strengthen their knowledge and role.

Staff reported feeling confident to raise concerns and were assured these would be listened to and acted upon. Regular team meetings provided opportunities to share information and encourage open communication. The registered manager said they were developing an environment where staff felt their views were valued and heard.
 

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 registered manager demonstrated a commitment to get to know staff and understand staff personal needs and diversity within its workforce and to promote an inclusive and fair working environment. During the assessment, staff raised no concerns regarding equality, diversity, or the culture of the service and consistently reported feeling supported in their roles. One staff member said, “They [managers] help me plan my life and my days off, I am really happy with this. This management is really good they always pick up the phone.”
 

The provider did not always 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.

Improvements were needed to strengthen the provider’s governance systems and record keeping. The provider had a range of governance and quality assurance systems; however, they had not ensured the systems were consistently effective in identifying and addressing areas of concern. Although regular audits and monitoring checks were undertaken, these had not identified the issues found during our inspection.

The provider had not operated effective systems to ensure people received punctual care from regular staff who had been assessed to be fully competent in understanding people’s care needs and support requirements. Feedback from people and their relatives supported this concern.

The provider had not ensured all notifiable incidents had been reported to CQC, in line with their statutory requirements. However, a new incident tracker was being implemented which prompted managers to notify concerns when relevant.

The provider did not consistently maintain complete, accurate and robust records. Not all staff records demonstrated staff had been safely recruited, inducted into the service and assessed as competent to deliver safe care. The provider had not always ensured accurate and complete records had been maintained in the management of people’s care records. People’s care records did not always contain clear guidance for staff on how to manage and reduce identified risks. Regular medicines audits had been completed; however, the audits had not identified gaps in the records of good medicine management practices.

The registered manager divided their time between the Gloucester branch and another service which they were also registered to manage. They were supported by an acting branch manager, who was responsible for the day-to-day management of the service. The registered manager said they were developing their knowledge about the operations of the Gloucester branch and implementing some improved practices such as improved communication and regular staff meetings. The provider had recently commissioned an independent consultant to carry out a mock inspection of the service and was developing an action plan to address the findings and recommendations identified.

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.

The branch manager stated they had good links with health and social care services and where required worked in close partnership with external professionals to ensure people were supported with any changes to their support needs from additional or emerging health and social care needs.
 

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The registered manager was supporting improvements across the service. The provider was reviewing their systems to document and monitor incidents to ensure all actions were taken and all relevant organisations were informed of any incidents. Feedback from staff identified communication and debriefs from the managers after incidents had improved. They reported there was an improving culture around the management of incidents within the service.