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• 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 we rated this key question Good. 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 in breach of legal regulation in relation to governance at the service.
 

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. However, systems and processes did not consistently demonstrate this was embedded at the service.

We received positive feedback about the culture of the service, with staff sharing an approachable and supportive management team.

The provider had a service user guide and statement of purpose. However, it was not clear how this was shared with people and staff. We found both documents required review due to both containing inaccurate information regarding the service provided, the roles and responsibilities of the staff and the oversight in place.
 

Leaders did not always demonstrate the skills, knowledge and oversight required to identify and address risks within the service. They did not always demonstrate the skills, knowledge, experience or credibility required to lead effectively.

The provider had not identified the concerns mentioned in this report prior to our assessment, and further improvement was required.

We found inconsistencies in records and audits, including those relating to care plans, staff training and call visits which the registered manager was unaware of. The responsibility for the completion of many checks and reviews had been delegated to senior members of care staff. This meant the provider was acting on inaccurate information about risks and performance.

It was clear from the feedback we received and the findings of our assessment there was a disparity between the experiences of people and staff compared to the documentation and evidence provided. By failing to have a robust governance system, the provider had not ensured the service was running safely or ensure action was taken where needed to make improvements.
 

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

Staff felt they would be listened to if they spoke up. A member of staff told us, “I feel able to speak up at work and have access to the whistleblowing process if needed. Management encourages staff to raise any concerns.”

The provider made available several methods and opportunities to staff to enable them to speak up.
 

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

The service had a diverse workforce.

Records showed that staff meetings, surveys and supervision had been completed. Staff confirmed these provided opportunities for them to provide feedback on their experiences.
 

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.

The provider’s processes to monitor the safety of the service were not effective. Quality assurance checks and audits were undertaken, but these were not being completed accurately by senior staff and the nominated individual. As a result, failings found at this assessment had not been identified or acted upon and the provider was in breach of regulation.

The service had an improvement plan however; this had been drawn up using inaccurate information and did not evidence inclusion of all potential sources of feedback such as audits findings from external reviews or satisfaction surveys. In addition, no specific actions had been recorded, no timescales for completion or a person designated as responsible. As such, we were not assured that the plan in place would lead to the improvements needed.

Following our assessment, the nominated individual gave assurances they had reviewed the feedback we provided and had taken some initial actions to make the necessary changes. They confirmed that further reviews of feedback was in progress.

Staff told us they knew their roles and what was expected of them. However, we received mixed feedback regarding the management processes with most staff not able to confirm any part where they felt able to contribute in driving improvements at the service.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The provider worked in partnership with GPs, various other healthcare services, and local authorities. The service was also a member of the local care providers association.
 

The provider did not always focus on continuous learning 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. They did not always actively contribute to safe, effective practice and research.

Processes were failing to evidence that learning happened when things went wrong. As described in other areas of this report, inaccuracies in information, audits and checks were not leading to improvements being made where needed.

Systems were not ensuring that documentary evidence was available to demonstrate care provided to people was consistently positive and safe, and that all reasonable steps had been taken to mitigate risk.