Becoming Care Services Limited

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.

This service scored 57 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Although the provider and registered manager had clear expectations of staff and told us they led by example, they did not have robust systems in place to regularly monitor the quality of care provided or staff performance as although they told us they carried out ‘spot-checks’ on staff, they could not evidence this was undertaken in a systematic way. As a result, they could not be assured that their vision, values and desired culture were being consistently embedded within the service as they were unable to evidence that all staff received regular spot checks.

The registered manager told us, “I expect staff to wear their uniform and are dressed appropriately. They are representing us. When I carry out care, I wear uniform too.” However, in the absence of recorded spot checks on staff and documented welfare checks with people using the service, the provider could not demonstrate that these expectations were being consistently met in practice. This lack of oversight meant they were unable to effectively monitor staff conduct, identify poor practice, or seek assurance that people were receiving care in line with the provider’s standards and expectations.

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.

Although the registered manager demonstrated a clear commitment to providing good-quality, person-centred, and safe care, they lacked the necessary skills and experience to effectively and robustly manage the service. This was evidenced by poor communication and a failure to respond promptly to requests for information from CQC, and a lack of knowledge when we discussed people with them when we were on site. There were also shortfalls in record-keeping, including a failure to accurately record important information and maintain adequate documentation.

Care plans were not consistently detailed or person-centred enough to effectively guide staff in meeting people's needs. In addition, the registered manager did not ensure that staff arrived on time for scheduled visits. Furthermore, there was a lack of records demonstrating that regular spot checks had been carried out on staff to monitor practice and ensure that care was being delivered safely and in line with expected standards.

People had mixed views on how well the service was run. One person told us, “In my opinion [management] may appear a little scattered but she gets the job done. She’s lovely though.” A relative said, “[Management name] will always discuss anything needed and pop in to ensure everything is okay.” Another told us, “I can rely on the carers always turning up.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
Staff had the opportunity to meet together either remotely or face to face. This gave them the opportunity to discuss any concerns with their peers and talk about work patterns or difficulties they may be experiencing.
Staff felt supported and said they would be happy to speak up should they identify any concerns. Although they all told us that so far, there had not been the need to. One staff member said, “They (management) are very good to me. They are always there for me.” Another staff member told us, “They (management) support us. I am happy to speak up about anything.”
 

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 told us, “We don’t discriminate. We are all here for the one goal and that is making sure our service users are being looked after. Everyone is welcomed into the team and we make sure staff know each other.” Staff told us they felt treated fairly and that management supported them with their work patterns. They also said that drivers were available to transport them between calls meaning no one was left to walk or take public transport. A staff member told us, “We get to know our rotas in advance so that we can have a healthy work-life balance.”

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.

Although the registered manager told us they audited accidents, incidents, care plans and people’s medicine records, they were unable to provide us with any evidence of these audits. They told us, “We don’t record anything, and I know if it’s not written down, it doesn’t happen. It is something I need to get better at.”

They went on to tell us, “I know I’m supposed to audit the care notes, but I haven’t yet. I do read them through, and if there is something that needs picking up, I will do so, but I don’t record the outcome of these.”

As a result of the lack of good governance arrangements within the service, the registered manager had failed to identify the shortfalls in people’s medicine records and care plans. Also, following our site visit, we requested evidence of some information that could not be found on the day. However, despite the registered manager agreeing to provide this to us, we did not receive anything, demonstrating a continued lack of oversight, organisation and good governance arrangements.

Although staff meetings were held, the registered manager did not record any notes from them, meaning there was no evidence of the discussions that had taken place, any concerns that had been raised, or actions agreed. This meant there was no audit trail to demonstrate that issues were being addressed appropriately. However, as the service was currently small, it meant the risk of people receiving unsafe or inappropriate care was reduced.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The registered manager had started to develop some links with local organisations to support them with building the service. This included involvements with the local church and social clubs, telling us, “We use it for marketing but also getting involved.”

In addition, they said they accessed information and support from organisation such as Skills for Care and kept themselves up to date with requirements of registration by watching CQC webinars for example.

However, the registered manager recognised the need to strengthen the links they already had and said they would start to investigate further avenues to support them and the people they cared for.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Although the registered manager had recently recruited an administrator and a carer worker in the office to support them, without robust governance arrangements in place, they were missing opportunities to learn and improve.

They recognised that improvements were needed in areas such as staff punctuality and record-keeping, telling us, “We now have [administrator name] to help.” However, despite being aware of these concerns, they had not sufficiently focused on embedding learning, improving oversight, and strengthening governance arrangements before continuing to take on additional care packages. This meant the service had expanded despite existing issues remaining unresolved.