Total Quality Care Services Ltd Birmingham

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 inspection we rated this key question good. At this assessment the rating has remained good.

This meant the service was managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 clear shared vision, strategy and culture which was based on transparency, equity, diversity and inclusion, and engagement. They understand the challenges and the needs of people in receipt of care from their service.

The management team explained their intentions for improving and developing the service. We could see from the staff meeting minutes there was an open discussion to improve the service and staff support. The provider updated their processes and procedures to reflect the improvements made during the assessment in response to the issues raised by us.

The management team understood the requirement to continually improve, monitor and evaluate the service, prioritising safe, high quality compassionate care.

The management team demonstrated a commitment to developing and promoting diversity within the staff team and the packages of care provided.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders did have the skills, knowledge, experience and credibility to lead effectively, with integrity, openness and honesty.

Leaders were visible within the service to their staff team. There was a stable management and staff team. Relatives spoke highly of the staff and management team. One relative shared with us how a manager drove their staff to their calls during the poor weather when staff had difficulty travelling.

Staff spoke positively about the management team. They told us they were always accessible to them and on the end of the phone. All staff we spoke with felt they could speak to the management team regarding any concerns or questions they may have, and they would be answered and acted on promptly. One staff member said, “I think they [management team] are really good and supportive. We receive support with supervision, training and support from the office when we need it.”

The provider had processes in place where people felt they could speak up and they would be listened to.

People told us they would speak up and felt their voice would be heard. Staff were provided with the relevant policies and procedures detailing what was expected of staff working for the service. Staff told us they felt able to raise any issues or concerns, including poor practice. Staff were confident the provider would listen to them. They advised us the management team were always accessible on the phone.

There was a whistleblowing policy in place for staff to access.

The provider worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider valued their workforce. Staff told us they felt listened to by the provider. The provider took steps to ensure staff felt they were heard and were confident to raise any concerns they may have.

The provider ensured they were regularly available to staff. They held regular meetings, providing staff with the opportunity to engage with them.

Staff told us they were happy working within the company and felt they were treated fairly. All staff said they were confident to bring any concerns to the provider. If their concerns were not dealt with appropriately, staff would not hesitate to contact the relevant authorities, such as the Care Quality Commission, the police or local authority.

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, or share this with others when appropriate.

Where audits and checks had been completed, these had not been completely effective and had not provided a consistent oversight of the service. For example, notwithstanding the reviewing of care plans regularly since their last inspection, we found there were risk assessments missing for some medical conditions and care plans were not always reflective of people’s current needs. Audits had failed to identify incorrect and missing information about people’s risks and needs.

Audits and checks had not identified some of the staff files had not been fully signed off and dated following the completion of the staff induction and shadowing. There were gaps in the provider’s audits and checks to validate staff references. Some references had not been followed up when there was no response or an alternative character reference sought in its place. The provider had failed to follow their own recruitment procedures.

All the issues identified at this assessment have been raised with the provider who has immediately taken the necessary action to implement changes to make the improvements. The provider has been fully involved in this assessment and has demonstrated in their willingness to learn from feedback to maintain and deliver a safe and effective service to people and their family members.

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

Staff felt there was an open approach between the service and the people they supported.

The provider had systems and processes in place to record contact with health and social care professionals and would make referrals where appropriate.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Staff meetings were held regularly, and minutes were kept of the meetings. These were used to discuss care practice. The meetings gave the provider the opportunity to remind staff about their training and the importance of working together to make sure the service provided good quality care for people.

The staff meetings were also used to discuss training and deadlines when training should be completed.

The provider had processes to gather formal feedback from people and maintained contact with people through home visits or phone calls. People told us the provider was responsive to any concerns and dealt with matters in a timely way.