Ontime Response Healthcare Ltd Norfolk

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. There were a lack of effective systems to provide clear oversight.

This service scored 62 (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. The service had a clear mission statement and company values. Regular spot checks were conducted in the service at different times to monitor the culture and staff meeting minutes evidenced an open environment where staff were encouraged to raise concerns to improve the service that is delivered. A staff member told us, “Yes, we do have meetings, and we are able to raise concerns and give feedback on issues that would have been discussed prior to that meeting.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. There was a long standing registered manager within the service. They ensured when there were incidents or concerns raised these were investigated thoroughly and duty of candour was applied where it was required. They sought support from local providers to aid with recruitment processes to remove any unconscious bias from the recruitment process as the service is a family run business.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was a whistleblowing policy in place which was clear for staff to follow and signposted staff with alternative contacts. Staff knew how to raise concerns. A staff member told us, “I freely speak out if needed. If something is not right for me, I’ll stand up for myself and talk to them asking, can you please help with this one and they always come along and help.” Supervisions evidenced staff were actively asked if there were any concerns they should be aware of.

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. There had been occasions where staff had received racist comments from people they supported. The registered manager ensured they supported any staff who had experienced this and arranged meetings with families and social workers to address the issue and relieve staff where it was required to protect them. Staff had reasonable adjustments made to support them in their role and flexible working arrangements were in place for staff where 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. There was a lack of provider oversight in the service. The provider could not evidence they conducted any quality assurance measures within the service and that they had clear oversight. We found care plan audits were ineffective and failed to identify the inconsistencies that we found. They failed to ensure appropriate risk assessments were in place around peoples care and support needs. They did not monitor care note entries to ensure care delivered was not task orientated. Other audits were ineffective.

Where issues were identified, actions that were produced did not evidence that they were rectified. They were vague and had no time scales set and often recorded as ongoing or within 4 weeks. There was no evidence they had been achieved or completed. There was no evidence of them being signed off.

The LA had conducted a PAMMS in April 2025 which is an audit tool used to assess quality and compliance of a service. The outcome of the PAMMS was requires improvement and produced several actions to rectify this. We found some of these actions were still outstanding and were the same as the concerns we found in our assessment.

The service failed to ensure appropriate safeguarding concerns were reported, although they took action to protect people, they did not share this information appropriately. The provider was not aware these were reportable concerns.

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 service supported people to transition into full time care settings when there was a change with their care and support needs. The registered manager worked closely with other providers and would share good practice and learning, and they felt it was a supportive network. A healthcare professional told us, “[Registered manager] is very open to feedback and I have a good relationship with them. They are very proactive with feedback that is given. We had meetings at first as communication was poor but that has improved.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. There were several actions that were still outstanding from audits and this prevented improvement within the service. However, any concerns around the care and support needs a person experienced were actioned and addressed and shared with the team to aid learning and improvement. Throughout the assessment where concerns were identified and discussed the registered manager provided assurance and evidence of action taken.