SSA Quality Care

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.

At our last assessment we rated this key question good. At this assessment the rating has changed to 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 and person-centred care.

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

This service scored 62 (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 consistently demonstrated a clear understanding of the service’s vision and values, which include respect, dignity, compassion, inclusion, person-centred care, and promoting independence. These values were embedded into daily practice and reinforced during staff inductions and ongoing supervision. One staff member commented, “Compassion being the core of our care and also promoting an inclusive environment where everyone feels valued and included.” Staff also spoke of the service’s mission to “deliver safe, compassionate, and personalised care that enhances quality of life and well-being.”

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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders were visible, approachable and led by example. Staff gave multiple examples of managers being supportive, participating in care delivery, and taking quick, appropriate action when issues arose. One staff member told us, “Managers are often active, checking in with staff and residents. They lead by example, especially in difficult situations.”

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

Staff were aware of the term ‘freedom to speak up’ and told us the service encouraged them to do this if they had any concerns. One member of staff said, “Leaders in our service encourage us to speak up by reminding us regularly during meetings that our concerns are important. They’ve created a supportive environment where we’re told that no issue is too small, especially if it affects a person’s safety, well-being, or quality of care.” Other staff confirmed there was an open door policy and managers were approachable. For example, “Leaders are approachable and supportive, fostering a positive work environment where I feel valued and listened to,” and “I feel I am very free and confident to raise any concerns I have without fear of victimisation.” Staff said any concerns they had raised were listened to and acted upon.

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 told us there was a code of conduct which outlined expected behaviour, to promote a culture of dignity and respect at work. They said they were treated fairly at the service and managers were flexible if they needed to take time off for appointments or swap shifts.

Comments included, “We are treated with dignity, respect and policies are in place for equality and fairness,” and “Expectations are clear, communication is open, and I have access to the same opportunities and support as my colleagues. I appreciate the efforts made by the leadership team to maintain a respectful and inclusive environment that supports teamwork and collaboration”. Another member of staff said, “I feel that my voice is heard, I’m treated fairly.”

The provider did not have clear systems of accountability and good governance. The quality of record keeping varied and did not always provide clear instructions or met professional standards. We found risk assessments were either not in place or did not routinely and consistently contain enough information to mitigate harm to people.

People’s records were not always representative of the individual. For instance, we found inconsistencies in people’s care plans. We found female care plans referred to “him” or “he” and we found records did not always use dignified language.

We found medicine records needed to improve. Where people had been prescribed ‘as required’ (PRN) medicine, their records did not routinely have information for staff to follow.

We found the provider’s quality assurance processes and policies were not routinely followed. We provided feedback to the provider and registered manager, who responded quickly to our feedback. However, the provider had not identified the concerns we found through their own quality assurance systems. In addition, we found the local authority had provided similar feedback to the service in May 2025. Although some aspects of quality monitoring had improved since then, some concerns still needed action.

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 provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. We found delays in action being taken following feedback from the local authority. For instance, the local authority had identified gaps in risk assessments when they visited the service in May 2025. At this inspection we continued to find areas of improvement in risk management.

The registered manager kept up to date with local and national initiatives affecting home care agencies.