Zi Mat Ltd

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.

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 and the registered manager demonstrated a positive, compassionate, listening culture that promoted openness and understanding between them and people using the service.

We asked the staff about the culture of the service and if they felt supported. Staff told us “Yes absolutely listened to. We are in a people business, and we have to understand people, it’s a people orientated business” and “We are always free to speak anything, our manager and office are very open to discussion. I am very comfortable speaking with them.”

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. However, our inspection found the oversight and governance of the service had not identified issues found during inspection.

The provider recognised improvements were needed to strengthen the leadership of the service and had developed an action plan outlining how they intended to address these issues. This included increasing the management team and using an external company to support the registered manager to improve governance, leadership, systems and processes.

We received positive feedback about the registered manager from people who used the service, comments included, “Manager is very friendly and visits often” and “Manager is very accessible, calls me monthly.”

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

Staff were supported by the registered manager to speak up if they had any concerns or suggestions. Staff were encouraged to speak to either the registered manager or the director of the service.

The provider had a whistleblowing policy in place. Staff told us they were able to raise concerns. Comments included, “We encourage people to speak up. In the last meeting I remember the manager speaking up and saying that people are encouraged to speak up and report things, it’s important and it’s valued” and “We always have ideas and they are always good with understanding and how we can improve our service.”

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 service had a diverse workforce, with staff employed from a wide range of backgrounds, cultures, and experiences. Staff told us they were treated fairly, supported and valued. Comments included “I’m very happy with the service the company is giving me, I’m getting everything I need, any training or support.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

During the onsite inspection the registered manager was not available. Documentation was not always easily accessible or available during the inspection, not all managers or office staff were able to access documents or aware they existed. For example, office staff was unaware there was an accident and incident matrix in place.

Quality assurance audits had been completed, however they were not consistent and had not identified the concerns we found during inspection. For example, staff file audits did not identify recruitment documents were not stored within a staff file, or where employment dates did not match reference dates.

Care planning documentation contained conflicting and out of date information, this had not been identified by the provider’s audits.

Feedback from people using the service was not consistently collected, records were limited in detail, and different feedback forms were used for different people, making it difficult to analyse themes or identify trends.

During the inspection, the registered manager developed an action plan to address the concerns raised. Although the registered manager took immediate action once concerns were raised, the governance systems in place had not enabled the provider to identify and address these issues prior to the inspection taking place.

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 registered manager told us they had worked closely with a local day centre after people’s relatives expressed a wish for them to attend. As the people involved were unable to communicate verbally, care staff accompanied them to the day centre to support their participation.

Staff also supported the staff at the day centre to understand people’s needs and methods of communication. This partnership working helped promote inclusion and enabled people to access community activities.

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 provider’s main aim was to expand the service by taking on additional packages of care. However, during the inspection the registered manager acknowledged that improvements were needed to current systems and processes before the service could safely expand.

We asked staff if they would change anything at the service. One staff member told us, “I don’t think there’s anything that can improve my job, the manager and the owner are looking into things to support us.”