In Caring Hands Wells

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.

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

This service scored 61 (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, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff spoke positively about the culture within the service, 1 staff member said, "I like the ethos" referring to approachable management and their willingness to listen. The registered manager understood challenges faced by people such as limited local activities and worked with staff and people’s families to identify suitable alternatives. This meant people remained involved in community activities despite local limitations. Staff prioritised people’s independence and ensured they were involved in their care. Staff felt well treated at work, the registered manager told us, “Staff and people are equally as important." This reflected a positive culture.

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. The registered manager spent time delivering care directly to people and was visible within the service. However, this reduced their time spent carrying out their managerial responsibilities. We found concerns during our assessment that were not identified independently by the registered manager.

Throughout the assessment the registered manager listened to our feedback and acknowledged that further improvements were necessary. This demonstrated transparency within the service and willingness to learn.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt comfortable raising concerns to the registered manager and the owners. One staff member told us, “The managers are very supportive and have an open-door policy and I feel valued and listened to here.” Staff were aware of whistleblowing procedures and escalation routes outside of the organisation such as the Local Authority. Staff did not raise any concerns with us during the assessment.

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. Staff had opportunities to request reasonable adjustments from the start of their employment. Staff were generally positive about the work environment, and their colleagues. One staff member told us, "I feel that I am treated fairly."

The provider did not have clear 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.

Governance systems and oversight were not robust enough in identifying, assessing and managing key risks to people. We identified concerns with medicines management, risks to people, application of the Mental Capacity Act 2005, recruitment and daily care records. Quality assurance processes lacked clear guidance and did not evidence what was reviewed or improved, this meant effective changes could not be made. There was no oversight of some areas such as daily care records and medicines which resulted in missed safety events, and limited opportunities for learning and continuous improvement. The provider failed to independently identify these shortfalls placing people at risk of harm.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The service worked well with different health and social care professionals. We received positive feedback from professionals about staff and management. One professional told us, “[Staff member] had developed really good rapport with the client and his parents” and “The carer was particularly open to adapting routines and to try suggested changes to try and improve her client’s care and support.” This demonstrated effective joint working. However, timely referrals for reviews, especially where ongoing concerns were identified, were not always made.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

We found several shortfalls during the assessment. Although the registered manager did start making improvements during the assessment, they did not identify these concerns independently. Therefore, it was unclear how the service implemented and embedded changes. This meant further improvements in continuous learning and time for improvements to embed was required.