Delight Supported Living 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 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 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. However, they did understand the challenges and the needs of people and their communities. The provider told us of their ambition to scale up the business and grow the number of people being supported. The management team and staff knew people well, and worked diligently to oversee the service, such as ‘real time’ monitoring of electronic care visits. However, wider systems and processes were not robust or formal enough to support this oversight, which could cause challenges if care was delivered to an increased number of people. The registered manager held details about key information at the service such as falls, pressure care, care plan reviews and staff supervisions. There was no overarching service development plan in place to tie this information together, demonstrate continuous learning and innovation, define metrics for success, and monitoring of any changes made.

Leaders understood the context in which the provider delivered care, treatment and support. They embodied the culture and values of their workforce and organisation. Despite this, leaders did not always have the skills, knowledge, experience and credibility to lead effectively. Staff told us they found the leadership team open, approachable and responsive. The registered manager brought clinical knowledge and experience, as a registered nurse, and was supported by a wider provider quality assurance team. However, some areas of the service were not in line with regulatory requirements as set out in this report, and this had not been identified and acted upon by leaders. In addition, not all people using the service knew who the registered manager was, as they had more contact with team leaders and other members of office staff in the community. A relative said, “I don’t know who the manager is.” Another relative said, “I think the manager is [team leader], they are my ‘go to’ person anyway.”

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 for staff to access if they chose to do so, with contact details for external agencies such as the CQC. However, staff told us they felt able to raise any issues or concerns openly with the leadership team, and felt confident action would be taken in response. Staff felt well supported, which led to an open and positive culture. A staff member told us, “I feel supported and valued. The registered manager is approachable, as are all management in the office.” There were regular team meetings held online, where information could be shared with staff at a time to suit them. However, meeting minutes showed limited input from staff, which was a missed opportunity for their knowledge and experience to be used to drive improvements at the service. We raised this with the provider to follow up.

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 received formal equality and diversity training to help ensure a fair environment for all. Staff confirmed they received their rotas in good time and had sufficient travel times and breaks. A staff member said, “The manager supports me by arranging flexible start and finishing times, which creates an environment where care workers are allowed to talk and reduces stress.” Another staff member said, “I recommend it (Delight Supported Living Ltd) as a good and caring company.”

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. The provider had not met their legal and regulatory responsibility to submit statutory notifications to the CQC, in relation to abuse or allegations of abuse, or serious injuries. Statutory notifications help the CQC to monitor potential risks at a location. Whilst appropriate action was taken in response to the incidents at the time, we found 7 notifications which had not been submitted to CQC, including missed medication, self-neglect and injuries such as pressure ulcers and a fractured hip. The registered manager began submitting these notifications retrospectively during the inspection process. The service completed weekly audits on operational areas such as missed and late visits, completion of eMARs and daily care notes. Whilst it was positive this was being completed, audits would benefit from some further detail to show which records were sampled, any impact and risk mitigation, or the outcome of actions taken. Governance systems in place had not identified shortfalls found at this inspection, in relation to recruitment, risk assessments, a lack of statutory notifications or failures in assessing people’s capacity.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. We received positive feedback about the service from professionals who worked with staff day to day. However, learning was not always demonstrated from external input. We found many of the same issues identified by a local authority quality audit in 2023 had still not been fully resolved, showing that changes made at the time were not embedded and sustained. This included in relation to areas such as recruitment, a lack of statutory CQC notifications and failure to complete mental capacity assessments as above.

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. We found service user satisfaction surveys had not been completed since 2023, and there was no clear action plan about how suggestions had been used to make improvements. The provider was unable to demonstrate in a formal way how they assessed changes at the service, analysed information to determine themes and trends, or used feedback to ensure continuous improvement. However, the leadership team were open to CQC feedback and took action straight away during the inspection process to address some of the issues raised. The registered manager confirmed they would use our feedback to further strengthen their service, and would be issuing a new satisfaction survey shortly to seek people’s views.