Marama Care HQ

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 provider was in breach of the legal regulations relating to the notification of incidents and good governance.

This service scored 61 (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 always demonstrate a clear culture of transparency. During this assessment, we identified a serious incident involving significant harm to a person that had not been reported to CQC as required by law.

The provider was in breach of the legal regulation relating to the notification of incidents.

Despite this, the provider had a shared vision and strategy based on equity, equality, diversity, and inclusion. Staff told us, “There’s a positive culture where communication is open”.

The provider had inclusive leaders at all levels who understood the context in which care, treatment, and support were delivered. They embodied the organisation’s culture and values. While we received positive feedback about the management team, this assessment identified issues that led to breaches of legal regulations, which had not been identified by the provider.

Staff told us they felt supported by the management team. Comments included, “The management are an amazing team, you can just talk to them about anything, and you can express yourself about how you feel and they encourage you and support you”, and “The management have been brilliant, I have had some health issues, and they have been really supportive and approachable”.

People’s advocates did not always feel confident that they could speak up or that their voice would be heard. While most relatives gave positive feedback about the service listening to them, some said they had raised concerns that were not acted upon.

Staff told us the management team was approachable and responsive to concerns. Comments included, “The management do more than supporting, if you communicate your issue they will definitely solve it”. and “The director down to the seniors are all very approachable, they will call for nothing apart from asking how you are doing, you find yourself opening up when there is that rapport between management and staff”.

People’s tenancy and care were clearly separated within their records. The management team gave examples of how they supported people to exercise their rights as tenants and empowered them to choose their care provider.

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them.

The provider told us, “We actively discourage discrimination, and we will support our staff if discrimination happens”, they explained if this happened, they allow the staff member to stop supporting that person, provide them with a break or step away. The provider was aware of their challenges within recruitment and wanted to recruit people of all cultures to celebrate a diverse workforce.

A staff member told us, “I came into the country from (name of country) Via the COS (Certificate of sponsorship) route. I would say from my very first interview to the last, my job offer and relocation process, Marama Care has been very professional. We were adequately informed and taken care of considering the negativity that had been surrounding COS and relocation, I never experienced anything bad”.

The provider completed bi-monthly business meeting reports that covered lessons learned, a featured policy, future planning, business performance, goals, and employee recognition. All staff were included to ensure they felt involved, valued, and part of the service’s development.

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.

Systems and processes were not robust enough to identify the issues we found during this assessment. Opportunities to improve the service were being missed. For example, the service did not always keep accurate records of the care and treatment provided or decisions made, as required under the Mental Capacity Act 2005. Risks to people’s health and safety were not always assessed, monitored, or updated, and staff were not always given clear guidance, putting people at risk of harm.

This was a breach of the regulation in relation to good governance.

Leaders understood there must be a separation between the care a person receives and their accommodation.

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

The service hosted events to bring together people using the service, their families, staff, and professionals, fostering a sense of community.

The registered manager, staff, and professionals told us the service operated as part of a multi-disciplinary team (MDT). This approach involved health and care professionals working collaboratively to plan and coordinate people’s care.

Social workers told us they were regularly updated by the service. One social worker told us, “My experience with them (Marama Care HQ) has been very positive. The family have also reported that they have a good communication with Marama care.”

The provider focused on improvements across the organisation and local systems. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The registered manager and provider told us they held weekly management meetings to review audit outcomes, safeguarding matters, handovers and areas for improvement.

A professional told us, “Marama have engaged positively with us, when there have been safeguarding and quality concerns raised, they attend meetings prepared to contribute and are responsive to requests for document or information, also they have engaged positively when concerns have been raised”.

We discussed the shortfalls identified during this assessment with the provider and registered manager. They were responsive, welcomed feedback, and began taking action to improve the quality of care and support for people using the service immediately.