Visiting Angels Northamptonshire

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 service since it was registered in April 2024. 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 the governance at the service.

This service scored 50 (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. They did not always understand the challenges and the needs of people and their communities.

The provider did not demonstrate a consistently positive and open culture, with feedback and our findings indicating a lack of transparency and openness. Although a governance framework was available, neither the provider nor the manager was familiar with it, and the manager obtained a copy during our assessment.

While the provider had assumed responsibility for the service, there was limited evidence to show that its culture, values and governance arrangements were embedded in practice. They acknowledged the concerns identified and showed a willingness to improve, including plans to increase management presence in the office. However, further work was needed to strengthen governance, oversight and quality assurance arrangements and to ensure practice was underpinned by effective policies, audits and action plans.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Feedback from staff about the leadership was mixed. One staff member told us, “Leadership has not been great; we had several managers come and go, but it's better now as [Manager name] is trying to get things sorted.” However, another person told us the service was not always managed professionally, as visit times changed frequently and communication needed to improve. We received similar mixed feedback from people and relatives; with one person saying, they felt the service was managed but were not aware who the current manager was. We shared this with the provider to address.

The service had experienced changes in both management and provider leadership, alongside gaps in recruitment, staff training and quality assurance systems. This indicated the provider's policies and procedures were not always being implemented effectively in practice. As a result, oversight and decision-making were not consistently robust, increasing the risk that concerns may not be identified, monitored or addressed promptly.

Further improvements were needed to strengthen leadership, clarify roles and responsibilities, and ensure effective oversight to deliver safe, effective, and person-centred care.

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

The provider had a whistleblowing policy in place which informed staff how to raise concerns. Staff were aware of the process, and one staff member told us, “I'm confident to speak to [Manager name], [Director name] and now [Provider name].” However, not all staff felt confident to speak with the manager. In addition, some people felt their concerns had not always been acted upon.

The provider currently did not have a ‘Freedom to Speak Up champion’ identified but assured us this would be looked into as part of their improvement plan.

We saw evidence that some staff had received supervision and attended team meetings. Staff told us meetings were not regular due to changes in management. Staff felt confident to speak with the manager and the provider when they visited the office frequently to collect personal protective equipment (PPE) and had opportunities to discuss their work through supervision and team meetings. One staff member told us when there was an issue with their pay, this was addressed promptly by the provider and confirmed in an email.

The provider did value diversity in their workforce. However, not all staff felt there was always effective inclusion, a fair culture and equity for people who worked for them.

Staff told us they were treated fairly. However, not all staff felt they were treated fairly and equally. While there were no formal reports of bullying or discrimination, feedback we received indicated potential discriminatory practices. Although the provider was aware of these concerns before this assessment, there was no evidence that action had been taken to investigate or address them. In addition, equality, diversity and inclusion training was not included in the provider's mandatory training programme. This meant the provider could not demonstrate it was promoting an inclusive culture or taking effective steps to identify, challenge and prevent discriminatory practices.

Staff shared examples of management support and flexible working arrangements to support their caring responsibilities and further learning. A staff member told us, “I supported the family [when their relative passed away] and I got good support from the manager at that time who told me to take the weekend off as the calls would be covered. I appreciated this.” Another staff member told us, “I love my job, love the clients and it’s a shame about the management being up and down; but we're getting there slowly.”

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 securely with others when appropriate.

The provider’s governance systems were ineffective. Although there had been changes at both provider and manager level, previous paper and digital audits had not been completed or made available. Audits we reviewed were either not completed fully or were unavailable, for instance, the medicines audits were not completed correctly. The digital care system was not used effectively to monitor staff punctuality or to identify and address missed visits.

There was no oversight of incidents, accidents and complaints. Complaints were not recorded and were not managed in line with the provider’s policy. We found limited transparency and no evidence that the duty of candour had been consistently upheld. The provider was investigating missing records, but they had not notified the Information Commissioner’s Office (ICO) and could not demonstrate that the associated risks had been appropriately assessed or mitigated.

We also identified significant concerns regarding recruitment, training, and competency processes, with mandatory training not fully reflecting staff responsibilities. Opportunities to gather feedback from people during spot checks were also missed. While delegated healthcare support was being provided for a specialist clinical intervention, governance arrangements were not in place to ensure safe delivery including staff competency checks.

Overall, there was a lack of effective provider oversight and scrutiny to identify and address shortfalls and to drive improvements. Although a governance framework existed, neither the provider nor the manager was aware of it until the assessment. These failings increased the risk of people not receiving safe and appropriate care and exposed them to avoidable harm.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and collaborated for improvement.

We found evidence of partnership working with external agencies, including the local authority and healthcare professionals. For example, guidance on a person’s modified diet had been incorporated into their care plan and staff were aware of it. The manager told us they liaised with healthcare professionals and made referrals when needed; however, this was not consistently recorded. This was raised with the manager and provider, and they assured us this would be addressed and monitored by the manager and provider.

A healthcare professional told us staff, and the manager worked collaboratively with them. However, they also identified a need for more consistent leadership and better clinical oversight to support the safe and effective delivery of care.

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.

The provider did not demonstrate a proactive approach to learning, improvement, or service development. Existing audit and monitoring mechanisms did not identified concerns and were therefore ineffective in providing oversight and assurance of service quality and safety. There was no service improvement plan or formal process to evidence learning and improvements made. Opportunities to seek and act on feedback, enhance practice, and strengthen the service culture was not consistently recognised or acted upon.

While the provider and manager took action to mitigate risks associated with staff working without the required pre-employment checks, they did not consistently identify, assess, and respond to other risks that we identified, demonstrating a weakness in governance. We shared our assessment findings with the provider. They were receptive and responded positively, outlining their plans to improve the service.

Following the assessment, the provider shared an action plan to address the identified shortfalls, including engaging external support to assist with implementing and sustaining the necessary improvements.