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

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 we rated this key question inadequate. At this assessment the rating has changed to 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 previously in breach of legal regulation 17 in relation to the systems in place to monitor the quality and safety of people’s care. Although we found some improvements at this assessment, they were not sufficient and the provider remained in breach of this regulation.

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 have a clear shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The regional manager shared a vision for the service which focused on placing people at the centre of their care and on empowering and developing the staff team, telling us, "Well-led starts at the top and affects everything else within the service."

However, we continued to find shortfalls across the service, including in staff practice and record keeping, so further action was needed to realise the regional manager's vision. The provider had not yet fully addressed some areas of concern identified at our last assessment. Leaders were aware of these areas and had plans in place to address them.

Several changes had taken place since our last assessment, including the recruitment of new staff, a programme of refurbishment, and strengthened oversight and governance arrangements. At the time of our visit the new management structure was in place on an interim basis. The regional manager told us the provider's chief executive had committed resources to address the issues in the service.

Staff across all the settings we visited described a positive, supportive culture focused on the people they supported. One support worker told us, "They're like family to us so we work together to do what's best for them." Another said, "There have been lots of new initiatives to improve the service. There are lots of changes to get used to but it is a lot better." One staff member told us, "We all work as a team." Feedback from people, relatives and staff indicated the provider was making improvements.

The provider had leaders who understood the context in which they delivered care and led with openness and honesty, but leadership capability was still developing and not yet embedded.

The location did not have a manager registered with CQC at the time of our assessment. The regional manager had applied to register. The provider focused on providing consistency and stability within each supported living setting. They had made changes to strengthen leadership across the settings and were clear and honest with staff about the areas for improvement.

Team leaders had a smaller span of control than at our previous assessment, and a new deputy manager post added a further level of oversight. Newly appointed managers told us about the support and training they received, including safeguarding escalation and recruitment training. The regional manager told us, “I meet with the new managers every two weeks, coach and mentor them and make sure they are in the services they are managing.”

Some staff told us they felt supported, but that turnover of staff and managers had been unsettling, while also describing an improving picture. One staff member said, “The managers in place now are really good, things will improve in the next year or two.” Some staff and relatives were less familiar with the new managers and wanted more visible leadership and engagement.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they felt able to raise concerns with managers, and that managers responded and provided guidance. Managers described an open-door policy and emphasised treating feedback confidentially. They demonstrated responsiveness by giving an example of how they were acting on a recent concern.

All the staff we spoke with understood whistleblowing and told us they would raise concerns externally if they felt issues were being ignored internally. One team leader told us they would have no issue raising concerns about staff if they failed to act, and said their manager had always taken appropriate action when they raised issues. Staff knew the provider's whistleblowing policy and the external partners they could contact.

The provider valued diversity in their workforce and worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had systems and practices in place to promote equality, diversity and inclusion. Leaders recognised the importance of inclusion and described plans to strengthen this area, including regular cultural awareness events and additional equality, diversity and inclusion training. Policies relating to equal opportunities and staff support were in place and up to date.

The provider supported staff through training and wellbeing initiatives, and leaders acted when concerns arose relating to inclusion. Staff told us they felt valued and well supported, described their teams as strong and mutually supportive, and said communication between staff was good. Staffing arrangements protected staff from working excessive hours, and staff working across services reduced the risk of cliques forming and closed cultures developing.

The new manager described plans for open recruitment events in both boroughs to attract more people into support work, involving the people the service supports.

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, or share this securely with others when appropriate.

The location did not have a registered manager. Applications were in progress with CQC at the time of our assessment. The management team had begun strengthening governance and had identified areas for improvement. Staff carried out checks and audits much more consistently than at our previous visit, with clear actions, timescales and responsibilities, and the system flagged overdue checks. Staff were clear about their responsibilities and newly appointed managers understood their role in oversight.

However, governance systems were not always effective. Audits and quality checks did not identify the issues we found during this assessment. At one site, we reviewed 27 weekly walking route checklists completed during 2026. Staff had recorded identical responses on each checklist, including the same formatting anomalies, with only the staff member's name and date changed. This meant the provider could not be assured the checks had been completed as recorded, or that they would identify risks to people.

Managers completed monthly quality assurance forms for April, May and June 2026 using identical, generic comments and did not identify any actions for improvement. The provider had also not reviewed a general environmental risk assessment for more than a year.

Governance systems did not identify incomplete risk assessments, unreported incidents, gaps in record keeping or shortfalls in care planning. The provider did not always submit required notifications to CQC. Records from engagement meetings also showed the provider repeatedly did not provide the monthly information commissioners requested.

The provider understood their duty to collaborate and work in partnership, and shared information and learning with partners, but did not always work consistently with commissioners.

Care records showed the provider worked in partnership with a range of healthcare and social care professionals, including GPs, speech and language therapy, mental health services, positive behaviour support teams, the police, advocates and other support agencies. This collaborative approach meant people's care responded to their changing needs. The Housing Advocate programme drove effective joint working with landlords, resulting in essential maintenance in people's homes. The provider engaged with local authority reviews and assessments, and staff supported people to be part of their local communities, including clubs, adult education, places of worship and volunteering. The provider was working on an improvement action plan in liaison with others.

The provider did not always focus on continuous learning and improvement. Although the provider and managers were driving to improve the service, without robust governance arrangements they did not identify all the areas requiring improvement. At our last inspection we found the provider’s governance systems were not effective in identifying significant shortfalls in the safety and quality of the service. At this assessment we found early signs of improvement, although more work was required.

The provider introduced an electronic care management system that was being embedded across the homes. The new management structure, staffing improvements, the Housing Advocate programme and improved financial safeguards demonstrated the provider's capacity to deliver improvement at service level. We also found improvements had been made relating to the safety of the environment, staffing arrangements including recruitment and deployment, and record-keeping in the Hackney settings.

The provider responded well to external feedback. The regional manager was responsive to our feedback on the day, took action to address our concerns and sent us evidence of actions completed and in progress. Staff identified lessons when things went wrong and put action plans in place, but audits did not always include meaningful analysis to drive improvement or help identify the issues we found. Lessons learned sections of incident records contained templated, generic wording rather than analysis of specific events, and staff did not always carry recommendations from incident reviews through into care planning. This meant a risk remained of the provider failing to identify potential harm promptly on a consistent basis, resulting in missed opportunities to learn and drive improvements.