CVB Homecare Ltd

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

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

This service scored 57 (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 clearly defined and embedded vision, strategy, and culture based on transparency, equity, human rights, diversity, inclusion, and engagement. Leaders and staff demonstrated an understanding of the challenges faced by people, as well as the needs of their local community.

A clear mission statement was in place, outlining the provider’s values.

Staff we spoke with reported feeling supported and spoke positively about the culture within the service. People did not raise any concerns.

Not all leaders demonstrated a clear understanding of their roles, responsibilities, or the context in which care, treatment, and support were delivered. For example, there were gaps in oversight, including limited systems to monitor staff training, competency, oversight and governance processes, which was not established or embedded.

The management team had limited leadership experience and had not consistently taken opportunities to develop this through learning and development. This contributed to a lack of clarity in relation to leadership responsibilities and regulatory requirements.

Governance arrangements were not in place. Systems to identify, monitor, and respond to risks were not established, and information was not always used effectively to drive improvement or ensure consistent oversight.

The registered manager acknowledged these concerns during the assessment and took immediate action to begin strengthening oversight, including introducing audit processes. However, these improvements were at an early stage and had not yet been embedded or demonstrated sustained impact.

While leaders demonstrated a compassionate and inclusive approach, and had relevant care knowledge and experience, this was not consistently supported by effective leadership systems or structured processes to ensure safe, high-quality care.

People told us they felt able to speak up and were confident that their concerns would be heard and acted upon.

Staff and people said they would feel confident to raise concerns if needed. The provider had a speaking-up policy in place, and staff were signposted to this through the staff handbook. The manager told us they acted on feedback; however, this was not always formally recorded. This limited the provider’s ability to demonstrate an open and transparent culture where concerns were consistently documented and addressed.

The provider did not always demonstrate how they valued diversity within their workforce or promoted an inclusive and fair culture.

While policies and training were in place, the provider could not be assured they were supporting equality and inclusion in practice. For example, there were no staff surveys or meeting records to show that staff views, including those with protected characteristics, were consistently sought or acted upon.

However, staff spoke positively about feeling supported and did not raise concerns about discrimination.

The provider did not have clearly defined roles, responsibilities, systems of accountability, or effective governance processes in place. Systems to monitor the quality and safety of the service were not established or operated effectively. The provider did not consistently act on information relating to risk, performance, and outcomes, and did not always ensure this information was accurately recorded, accessible, or shared to support safe and effective care.

The provider had not completed formal audits, which limited their ability to maintain effective oversight of service quality and performance. However, when this was raised during the assessment, the registered manager took prompt action to introduce a structured audit schedule to strengthen governance arrangements going forward, including audits of staff training and medicines management.

Key information required to support effective oversight was not always available on site. Records were missing, incomplete, or not readily accessible, which reduced the provider’s ability to monitor, assess, and improve the quality and safety of the service in a timely and structured way.

This meant that governance systems were not fully established or embedded. As a result, there was limited assurance that risks were consistently identified, assessed, and managed, or that accurate and up-to-date information was used to inform decision-making, drive improvement, and ensure the delivery of high-quality care.

The provider demonstrated an understanding of their duty to collaborate and work in partnership with other services and professionals to ensure care was seamless for people. They shared relevant information with partners, who described a proactive and collaborative approach to supporting improvements.

Professionals we spoke with confirmed the provider worked collaboratively and shared information when required.

The provider did not always demonstrate how they promoted continuous learning, innovation, and improvement across the organisation and wider system. They were unable to consistently evidence how creative approaches were used to improve people’s experiences, outcomes, or quality of life, and learning and development was not always clearly documented.

Leaders understood where improvements were needed, acknowledged areas for change, and responded positively to feedback. The registered manager began making improvements from the day of the assessment. However, this was not yet applied consistently, and the impact of changes on people’s outcomes was not routinely reviewed or measured.