Archived: Social Care Solutions Limited (Northampton)

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• 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 inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance and fit and proper persons. Systems in place were not robust enough to assess, monitor and improve the quality and safety of the services being provided to people. Statutory notifications were either not submitted or there had been a delay in submitting them for abuse or allegations of abuse. Audits completed were ineffective. Systems and processes in place did not support learning and improvement.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received mixed feedback from staff about working at the service. Although the provider had a vision and a set of values known as ‘CHOICE’ (caring, honest, one team, innovative, courageous and equal), we found the provider and manager had not implemented these effectively in the service to guide the culture or behaviours to enable staff to work in a person-centred way.

The provider’s organisational structure had not been sufficiently implemented or embedded, as leaders were not able to translate the provider’s vision, values, or behaviours into practice, to demonstrate how they were going to improve, and embed a person-centred culture.

During the assessment, we were advised the provider had numerous support functions in the organisational structure to support local leaders, including quality, human resources, estates, and positive behaviour support. However, we found there had not been sufficient face to face visits, initial assessments, or on-going support from these teams. For example, although referrals had been made for input from the positive behaviour support team, we were told they were not actively supporting the service to make improvements. One staff member said, “It depends how you define support.”

People and staff were not involved in decision making, implementing systems or included in improving the service. People were receiving care from staff whose focus was on carrying out a task rather than delivering care in a person-centred way.

The provider had not locally implemented their vision, strategy and culture based on transparency, equity, equality and human rights, diversity, inclusion, and engagement. This meant leaders had not embedded a person-centred culture in the service.
 

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support, or who embodied the culture and values of their workforce and organisation.

At the time of the assessment there wasn’t a manager registered with CQC. The provider had employed a manager with a view to registering, however, they were currently absent from the service. The area manager had assumed responsibility for overseeing the service in the absence of a manager. However, we found the area manager was also responsible for other local services under a different registration but was also the registered manager for services in another County. This meant the provider had not provided enough support or resources to ensure adequate oversight of the service.

Relatives told us they were not aware of who was managing the service. One relative said, “I don’t know the names of managers because they have changed.” Another relative told us, “There have been lots of changes, and I don’t know the names of managers.” This meant relatives did not have a named person to contact if they had a concern.

Although the service was going through a challenging period there was a lack of effective and timely action. We were told key leaders were not visible. For example, the regional director had visited the week of our assessment, however, not all homes received a visit, and no further support or resources were identified to support improvements. We were told the quality manager responsible for the service had never been to the registered office or visited any of the supported living homes.

Relatives raised concerns with us about the leadership of the service. A relative told us, “I don’t have confidence in the management.” Another relative told us, “I don’t think it’s well-led but new people are in.”

We found leaders did not have the skills, knowledge, or experience required to lead effectively, and they did not do so with integrity, openness, and honesty. A staff member told us leaders were, “Not easily accessible.” We found junior leaders were enthusiastic and wanted to lead and learn, however, there was no effective leadership development to enable them to make meaningful change.
 

People did not always feel they could speak up and that their voice would be heard.

The provider had policies in place in relation to whistleblowing, complaints and speaking out. However, we found there was a culture of not reporting or acting on concerns at all levels of the service and no effective plan to address this. This meant that people were at risk of abuse being unreported and action not being taken to protect people from the risk of harm.

We were not assured leaders understood the need for change or would act on information or concerns being raised with them to bring about meaningful improvement. For example, one staff member told us they first reported concerns about reporting and recording of incidents to senior leaders in October 2024, after a serious incident was shared with the provider by CQC. However, we found this continued to be a concern during this assessment meaning there had been missed opportunities to act on feedback.
 

The provider did not value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider employed staff from a diverse background, with strong skills and knowledge, however, the management team did not celebrate this. We had mixed views from staff regarding how they were treated. Some staff were positive about their job role whilst others told us they were not happy and looking for other work. Some staff told us they did not feel all staff were treated equally. For example, one staff member told us they found their personal circumstances were not always taken into consideration when the shift rota was completed.

We were not assured the working environment was inclusive, and staff’s wellbeing was considered consistently. For example, the provider had a blame culture when things went wrong and focussed on applying blame to individuals rather than learn from organisational failures. This meant the provider did not ensure the service had a positive culture and did not always support staff to deliver better outcomes for people.
 

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.

The provider did not evidence they had established robust governance processes to ensure there was good quality assurance and management oversight. The governance systems failed to adequately assess, monitor, and mitigate risks relating to health, safety and welfare of people using the service. For example, the use of the compliance system to report and record incidents was not robust and incidents had not been accurately or fully investigated. We found the lack of the systems effectiveness was in part related to the competency of some leaders’ ability to use the electronic system. This meant systems were not being used to learn lessons and people were being place at risk of harm from repeated incidents.

Systems and processes did not always ensure incidents were reported to the local authority and/or CQC in line with provider’s regulatory responsibilities. For example, statutory notifications had either not been submitted or there had been a delay in submitting these for incidents of abuse or allegations of abuse. Notifications lacked clarity and the assurance of timely action to prevent harm, or reoccurrence.

The provider’s tiered governance system failed to provide adequate oversight of the quality of service being delivered. Audits and improvement plans were not effective. Systems and processes had not been adequately implemented and failed to support the delivery of sustainable improvements to address identified concerns. For example, an organisational audit in October 2024 highlighted shortfalls in the service, however, many actions were marked as ‘completed’ without adequate validation to confirm these had been embedded in care delivery. During our assessment, we found the majority of the ‘completed’ actions were still outstanding.

The provider’s systems and processes had failed to ensure staff had the skills, observation, and information for staff to know how to provide safe care that met people’s needs. For example, care records, including care plans and risk assessments, did not include all of people’s current information. This meant people were at risk of not receiving care that met their needs.

People’s relatives raised concerns with us about the management of the service. One relative said, “There seems to be a lot wrong.” Another relative told us, “Management are covering too many services.”

Our assessment found widespread and significant shortfalls. We identified regulatory breaches relating to dignity and respect, safe care and treatment, staffing, fit and proper persons, and good governance. At the time of the assessment the provider was not able to assure us they had adequate resources in place to address the shortfalls we identified, and those already identified by the provider.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

The provider’s lack of oversight and monitoring at the service impacted the effectiveness of collaborative working and sharing of information, as learning and quality improvement was not routinely taking place. The local authority had increased monitoring of the care provided by the service as they were not assured by the provider’s response to identified concerns.

The service did not work effectively with people, their representatives, staff, or partners to build a culture that focused on enabling people to enjoy their lives and live in a person-centred way. For example, staff told us one individual had been discharged from hospital on several occasions without the adequate equipment, support, or referrals to meet their needs. We raised this with the area manager who told us the discharges took place without an assessment and not all equipment, training or support was in place to enable a safe discharge. Concerns had not been shared with partners meaning there had been several unsafe discharges.

People’s care plans were not always up to date, detailed and accurate, therefore, it was not clear partnership working was always fully supporting effective care.
 

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

Although the provider holds several accreditations and affiliations that support driving quality in social care and has been recognised through awards for learning, improvement, and innovation nationally. A culture of learning, improving and innovation was not evident in the service.

The provider had systems and processes in place to analyse and learn from incidents, complaints, and audits. However, the local implementation of these did not support learning, improvement, and innovation. Quality assurance processes did not provide adequate oversight for leaders and were not effective in ensuring continuous improvement and sustainability. For example, the provider’s-tiered governance system was not effective. We found most audits in the supported living homes had been ticked by staff as compliant, as no compliance issues had been identified, and no actions required. Other audits had been assessed as ‘good,’ ‘very good’ or ‘compliant’ and did not highlight the significant shortfalls we found during this assessment. The provider failed to have sufficient oversight of the proficiency of staff and leaders who were taking responsibility for completing audits.

Leaders did not have a good understanding of how to make improvements happen. The approach to making improvements was inconsistent and did not include effective monitoring of outcomes and impact. For example, the provider’s quality team completed an organisational audit of some of the supported living homes in October 2024. This audit scored 52% and was considered an ‘adequate audit’ using the provider’s scoring matrix. An action plan was created for the identified shortfalls. The area manager told us there was a delay in the audit and action plan being shared with the service; this was received by the area manager in December 2024. The provider’s audit highlighted some, but not all, of the concerns we identified during this assessment. However, we found the provider’s action plan had not been used as an effective tool to deliver learning and improvement. For example, one action identified people needed to be involved in the review of their care and support. Another action identified people needed to have goals relevant to them. Although these actions and several others had been marked as ‘completed’ on the provider’s action plan, we found during the assessment the shortfalls continued to exist.

The provider’s oversight of systems and processes to support learning, improvement and innovation had failed to deliver sustainable improvements. Where learning had been identified, this had not been used to make improvements across the service. This meant people were being placed at risk of receiving a poor quality of life due to a lack of continuous learning and improvement.