Home Office

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. This key question has been rated inadequate. This meant there were widespread shortfalls in leadership and governance systems. 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 governance.

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.

Home Office (Julie’s Home Help Ltd) had grown from a companionship service to a service providing ‘personal care’ care and support to people in their own homes. The service had grown in order to ensure they could continue to support people as their care and support needs changed.

The service didn’t have a clear strategy and vision detailing its aims and objectives. Staff were therefore not clear how their role supported the service’s vision and aims and objectives.

This was the provider’s first inspection, and throughout the process they were open, receptive, and demonstrated a clear commitment to learning and improving the service. They responded promptly to our feedback and were keen to begin to make the necessary improvements to support compliance with regulations.

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.

People who used the service and staff spoke highly of the registered manager, they felt they were approachable and were confident that any issues or concerns raised would be dealt with promptly and appropriately.

Although the registered manager had experience in delivering care, their ability to provide robust oversight and strategic management was limited. This limited their ability to lead a service that promoted equality, diversity, and compliance with legal standards. This was the provider’s and registered manager’s first inspection, throughout the process they were open, receptive, and demonstrated a clear commitment to learning and improving the service.

People were not always supported with the information or encouragement needed to raise concerns or express their views, which limited opportunities for their voice to be heard.

The systems and processes in place were not sufficiently robust to protect the safety and welfare of staff. A basic whistleblowing policy was in place, however we found that staff were not consistently aware of this policy or how to access it. For example, one staff member said, “I would tell the registered manager and then assume they would give me a whistleblowing form to complete”. In addition, staff reported that team meetings were not being held, which reduced opportunities for collective discussion and feedback.

People using the service, and their relatives, also told us they had not been given a formal opportunity to provide feedback. Despite this, they stated they would feel comfortable approaching the registered manager if they needed to raise any concerns.

The provider did not consistently promote or support robust equality and diversity practices within the workforce.

The provider did not have effective systems or processes in place to support and develop an inclusive workforce. Staff did not receive regular supervision or annual appraisals to ensure ongoing support and development.

There was a basic Equality and Health Inequalities statement in place and Equality and Diversity training was available to staff via an online course. However, the provider did not maintain accurate or reliable training records, and we could not be assured the information held was correct. For example, records showed that all staff had completed this training; however, some staff members could not recall doing so, with one stating, “it might have been one of the courses I did”. Consequently, we were not assured that all staff had been equipped with the knowledge and understanding necessary to demonstrate awareness in this area.

Despite these omissions, there was no impact on people who use the service in relation to equality and diversity during our inspection.

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.
Governance processes were not effective in ensuring people’s safety, protecting their rights, or ensuring staff had the necessary skills to meet people’s needs. As a result, the systems in place did not drive improvement, failed to identify the concerns highlighted during this assessment, and could not be relied upon to monitor quality or manage risk. Multiple issues were identified across all

areas of the service including person-centred care, safeguarding, training, recruitment, supervision, recording, MCA compliance, consent, care planning, risk management and the management of people’s medicines. These widespread shortfalls reflected a lack of effective oversight and accountability, increasing the risk of poor outcomes for people using the service.

The provider did not have an effective business continuity plan in place, to ensure vulnerable clients would continue to be supported safely during unexpected events impacting normal operations.

This was the provider’s first inspection, and throughout the process they were open, receptive, and demonstrated a clear commitment to learning and improving the service. They responded promptly to our feedback.

The provider did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

People were supported to attend a fortnightly social event held at a local community hall. The registered manager described this as a well-attended activity that provided opportunities for people to socialise and engage in the community in a relaxed environment. However, we received mixed feedback from a representative of the Local Authority regarding their recent interactions with the service. They reported that the registered manager was pleasant and approachable, and that carers were friendly, with [name] appearing comfortable in their presence. However, the representative also told us that the registered manager did not respond promptly when documentation and invoices were requested.

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.

The absence of robust governance processes and oversight resulted in the provider not identifying the service failings highlighted during this assessment. There was no formal service improvement or development plan in place to systematically identify areas requiring improvement, detail the necessary actions, assign clear responsibilities, or set achievable timescales. Consequently, the quality of service delivery had not been adequately monitored. Potential risks to individuals were not consistently recognised and opportunities for learning and continuous improvement were missed.