Three C's Support

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 under the previous provider, we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulation in relation to the lack of robust governance at the service.

The service was in breach of legal regulation in relation to staffing levels, failure to submit notifications of incidents and safeguarding service users from abuse.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

There was a lack of shared direction and cohesive culture across the service. The service did not have a visible strong direction and culture that was shared between staff and leaders. There was little evidence of effective leadership guiding day-to-day practice. This absence of a clear, shared vision contributed to inconsistent standards of care, and a lack of accountability. Without a strong and inclusive culture, staff were not supported to deliver high-quality, person-centred care, and this placed people at increased risk of receiving care that did not meet their individual needs or uphold their dignity.

The structural issues that had resulted in a high turnover of managers and staffing issues meant that staff were not always sure of where to turn should they have concerns about their work, or the people they supported. Some managers were employed on short-term contracts which left staff and teams feeling unstable. One support worker told us, “We just want things to settle, to have stable management.”

The quality management systems had not identified or addressed. There were regulatory breaches relating to medicines, infection prevention and control, person-centred care, safeguarding people from abuse and improper treatment and assessing, monitoring and mitigating risks to people's safety.

A partnership agency told us, “Leadership and governance structures appear fragmented and ineffective. Governance failures identified at one service were mirrored at several homes suggesting provider-level issues rather than isolated service concerns. Internal audits failed to detect serious risks, and strategic oversight was lacking. While the provider has engaged constructively post-inspection, the scale and persistence of concerns require sustained cultural change and robust leadership intervention”.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The provider did not always lead effectively. The high turnover of managers meant that essential checks on the support people received were not always carried out or were not carried out effectively. This left people at significant risk of abuse. For example, robust checks were not carried out on how people were supported to manage their day-to-day finances. Although the provider had taken steps to rectify this, people’s money was stolen from them due to the service’s lack of capable and consistent managers. The service improvement manager told us, “There should have been monthly audits by the team leader, but this didn’t happen.”

Some staff members told us they did not feel always well supported by leaders. One support worker told us, “We get threatened with suspension if we raise any concerns.” Another said, “Staff do not receive any support in the performance of their duties in making life comfortable for the people we support. Staff feel unable to say no to anything asked of them as we are bullied and coerced.”

Other support workers told us they felt well supported by their direct line managers. One told us, “[Team leader] is very helpful if we have any issues.”

We saw that most staff teams had periodic meetings where some issues were discussed, relating to the provider, the service and the people they supported. Minutes of these meetings were quite similar from month to month, and we could see that some issues that had been identified through other means (safeguarding concerns, complaints and incidents) were not discussed in team meetings to share any learning and improve the support people received.

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

Systems and processes were always in place to support people, relatives, and staff in speaking up. The provider told us they welcomed feedback from people, relatives and staff however, staff did not feel they could always approach the management team with issues as they were not confident these would be responded to appropriately. The provider did not provide regular opportunities to provide feedback about the running of the service. The staff felt the service provider had not been open to feedback to make service improvements.

A staff member said, “We have a black suggestion box by the front door for people to raise concerns anonymously”. During our visit to one of the supported living settings a person asked us, “Why have I got a suggestion box near my phone? I am sure it hadn’t been there yesterday. And in the last 24 hours a ‘wash your hands’ sign was put up in his bathroom without asking me”.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider employed a diverse staff team including different ethnic backgrounds and genders. Staff did not receive regular opportunities to provide feedback about the service. Staff meetings were not always utilised as an opportunity for staff to feedback about their ideas or concerns.

There was inconsistent evidence of team meetings and supervisions to show staff were included in decision making and improvements were required to ensure equity in how staff across the service working in the service were viewed and treated.

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 service provider had effective systems in place to enable them to have a robust oversight of the quality of the service being provided and to identify and assess risks however these were not utilised effectively to improve the quality and safety of people’s support.

There was a disconnect between what service leaders were relaying to us during the inspection, what was recorded on official documentation, and what was actually going on in the supported living settings and with the support people received. The interim service manager said, “Historically [this local authority] contract has been chaotic and continues to be .”Although the provider had audits and checks in place, these were not always effective in identifying issues of concern in the supported living settings and in the support people received. We reviewed 12 team leader monthly audits (four months in three homes) and there was one action arising from all 12. The audits stated that support plans had been updated, yet the support plans we reviewed for those particular homes contained out of date information, and one had not been updated since 2015. The audits were not effective at identifying the issues of concern we and the local authority had identified through our visits.

The local authority audit in April 2025 resulted in a comprehensive, detailed and thorough action plan; however, this was not developed until August 2025, and some actions that were marked as completed that had a direct impact on people’s quality of life had not yet filtered down into the support people received. For example, one action marked as completed in all homes was ‘Require monthly walk-throughs and unannounced spot checks by senior staff to ensure hygiene compliance is maintained’, yet one of the homes we visited was cluttered and dirty. The action plan also stated ‘[Electronic care planning and recording system] has gone live and staff have been encouraged to use it to record daily support log’, yet the system was not being used in any of the homes we visited, nor had any of the support staff been trained in its use. One of the supported living settings were receiving dedicated support from a service improvement officer, part of the provider’s quality assurance team. They recognised the work the team had to do to improve the service. They told us, “We have to motivate the staff to have aspirations for people. We have a multi-disciplinary team meeting each month to work on the action plan we have for the service.”

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. However, some people’s care was coordinated, and they were supported by a number of different health professionals.

Partner agencies were not assured the service was operating safely. A professional working with the service told us, “The provider has not demonstrated flexibility or responsiveness to changing needs. Concerns raised by external agencies persisted for months without formal escalation.”

Staff told us they worked with a range of external partners including, volunteers, external health and social care professionals and commissioners. Staff told us they were supported by external partners.

There was evidence of some collaboration between staff and healthcare professionals, such as the GP, district nursing team, physiotherapist, dieticians and the chiropodist. This helped ensure people received input in their care. However, many people’s care plans were not always up to date, detailed and accurate therefore we could not be assured partnership working was always fully supporting effective care.

A lack of oversight and monitoring at the service impacted the effectiveness of collaborative working and sharing of information, as learning and quality improvement was not routinely taking place. At the time of the inspection, many partner agencies were not assured the service was operating safely subsequently some homes under this service were placed under local authority monitoring and support process to ensure appropriate procedures were in place to keep people safe.

Learning, improvement and innovation

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

There were not effective systems in place to ensure continuous learning and improvement at the service. Our assessment found widespread and significant shortfalls which the provider had not identified and addressed through their quality management systems. There was no clear system in place across the service to encourage staff reflection and learning from events and incidents to discuss where things had gone wrong, and what needed to happen to prevent such events happening again.

Although an action plan had been implemented in response to concerns identified by the local authority in April 2025, the required improvements had not yet been achieved.