31-32, Southernhay East

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

We assessed all of the quality statements within the well led key question. Our rating for this question is requires improvement. Whilst people and relatives we spoke with said they were happy with their care, the provider and registered manager did not have effective governance and management systems to have clear oversight of the service and ensure it was running smoothly, especially as the service grew. We did not find people receiving a service had any negative outcomes, but we found a breach of the legal regulation relating to good governance. The provider and registered manager were responsive to our findings and keen to make improvements. The provider had already started to take action to address these concerns, including reviewing their policies and procedures, staff training and support, and reviewing care plans. Most staff were provided with fair and equal opportunity at work and were valued and respected. Most staff were positive about the management team and felt confident that any concerns raised would be addressed. However, policies and procedures did not formally support staff and enable them to share any issues or meet face to face regularly as a team. Oversight and governance of staff training, staff supervision and appraisals, spot checks, complaints, accidents and incidents, care plan reviews, survey results and the on-call system were lacking. Management of missed visits, environmental risk assessments and self-neglect were also lacking. The registered manager was aware of their statutory responsibilities in relation to informing CQC of certain changes, such as applying to relocate the registered office.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a lack of formal staff meetings and supervision to ensure information and support was consistent. There was no evidence that staff met together as a team for learning or sharing of information to ensure a shared direction and embedding a positive culture. However, most staff said they were happy working for the service and enjoyed their work. The registered manager was knowledgeable about people and their needs and spoke compassionately about the care they provided. They told us they focused on delivering good quality care to people and were keen to make improvements in governance and formalise staff support and oversight.

We did not find that a lack of oversight had affected people receiving the service negatively. However, there was no recorded overview or action plan to ensure that processes and procedures were adhered to smoothly. The management team undertook spot checks to observe staff practice and make sure staff were focused on delivering high-quality care and support to people and meeting their individual needs and rights. However, although these were documented there was no record to show which staff had had a spot check. Training was provided but there were many gaps in the training matrix and initial training consisted of many topics covered briefly in 2 days. Therefore, it was not clear whether staff had sufficient knowledge to consistently meet peoples’ needs. Competency checks had not been recorded to ensure staff consistently knew what to do. There was no opportunity to discuss training to ensure staff understood the training they had completed in the induction or online. The registered manager had completed some specialist training but there was no record of this being shared with staff.

Most staff told us they felt supported by management. However, some staff did not feel supported or that work was allocated fairly. A number of staff were family and friends of the management team. A lack of staff meetings and 1 to 1 staff supervisions did not ensure information and issues were able to be raised within a safe process Staff comments included, “I can always approach my supervisor for guidance or support when needed”, “Scheduling could be improved [to improve the routes for staff when visiting people]” and “Yes I feel supported by the provider, but improvements could allow enough driving time between client visits and improve communication channels.” Most staff said they had regular supervision/appraisals and training, but we did not see evidence of this recorded. The registered manager said they tried to support staff and staff told us they could contact them at any time. However, telephone support and communication was not formally recorded. A lack of a formal on call system sometimes meant that staff were contacted regularly at inappropriate times to cover shifts at very short notice, which affected their well-being. The feedback we received from partners who worked with the service had confidence in the leadership of the service. They felt the leadership team were knowledgeable and accommodating when discussing assessing potential new service users and ensuring their needs could be met . If specialist care was required, the registered manager told us they ensured staff providing that care were trained in that topic. This was recorded.

The registered manager was sometimes involved in delivering care and said they provided regular support and guidance to staff. However, this was not formally recorded and evidenced in supervision, and appraisal records. Staff said they could escalate any concerns relating to people they were providing care to with the registered manager and the registered manager gave us evidence of this with healthcare professionals agreeing. However, this was not always formally recorded in care plans. For example, the service did not have a policy about missed visits and service user self-neglect to ensure support and referrals were made in a timely way. The registered manager was rectifying this as soon as possible. There was no evidence of any team meetings held apart from a very brief discussion some months ago. However, this was undated and did not record attendees. The provider and registered manager were receptive to advice and support from the local authority to improve governance and oversight of the service.

Most staff told us they felt confident in raising any concerns to the registered manager. However, some did not and felt any negative comments could affect the work offered or they were afraid of being ‘told off’. There was no evidence of sharing and discussion of the whistleblowing policy or others with staff. However, most staff said the registered manager was available to assistance when they were out working with people.

There was a whistleblowing policy in place but there were no records of whether staff were aware and had signed to confirm they had read and understood policies. There were no opportunities or records to ensure staff had been able to discuss or go through polices and procedures. Systems and processes were in place to ensure recruitment practices were appropriately completed.

The providers/registered manager acknowledged that staff meetings and the processes for formally sharing of information with staff required improvement. Staff mainly said they felt supported through telephone calls or that they were able to contact the registered manager when they needed support. However, not all staff felt well supported. We shared information about this with the registered manager so they could address the issue.

The provider/registered manager were keen to improve consistent information sharing with formal processes to ensure all staff felt supported and included. Staff mainly felt supported, but some staff did not feel their issues or concerns were managed well. Staff had access to external support and there was evidence of additional support relating to transport and personal support.

Although the registered manager was knowledgeable about peoples’ needs, they were lacking in knowledge about governance requirements and quality statements . We could not be assured the service had effective systems to ensure the leadership team had adequate oversight of the service. There was a lack of governance and oversight by the leadership team relating to training, competency of staff, supervision and appraisals, spot checks, overall staff support and on call arrangements. The leadership team did not conduct any audits relating to care plan reviews, accidents and incidents, environmental risk assessments, daily records reviews, survey analysis and complaints management. This meant they were unaware where they needed to make improvements to the service. However, our review did not identify that this had a negative impact on people’s care as the staff and management team had a good understanding of people’s individual needs. and People also gave us positive feedback about the care they received.

The service did not have effective quality assurance processes and procedures, although care plans were detailed and reflected peoples’ needs. The lack of good governance had not been identified by the provider and registered manager and there was no action plan to monitor ongoing improvements. They said they supported staff, but this was not managed well or recorded formally through effective, consistent processes. This constitutes a breach in regulation regarding good governance). The registered manager was aware of their responsibilities regarding duty of candour, which is their legal responsibility to be open and honest with people when something goes wrong. They had submitted the necessary notifications to the Care Quality Commission, as required.

People did not raise concerns in this area. Feedback received was that the service worked well with other professionals.

The service worked in partnership with others to meet the needs of people. The registered manager told us they had worked with the local authority to provide staff to support people whose care needs were not being met in an emergency situation. Local partners of the service confirmed this.

The feedback we received from partners was positive.

People did not express any concerns with the service working in partnership with other professionals, such as GPs, social workers and end of life professionals. The registered manager said they had good working relationships with community health care teams and the local authorities. However, records were sometimes kept on their phone rather than formally recorded.

The registered manager did attend various training sessions with the local authority but there were no records to show they shared this information with the wider staff team. Therefore, we could not be sure all staff had completed training to enable them to meet peoples’ needs. The provider and registered manager collaborated fully with this assessment, and were receptive to our findings and assured us they would act on the issues found.

During this assessment, we found a lack of evidence that the service leaders recorded and analysed. The registered manager did not have systems and processes to analyse incidents and accidents and use information from audits to make positive changes and improvements to the quality of the service. They ensured people, relatives and staff were asked for their feedback and opinions however, there was no analysis of findings or action plan to monitor the effectiveness of improvements. The feedback we received from people, relatives and partners did not highlight any concerns. We heard examples of how risk had been managed well by the registered manager and people and relatives did not raise any issues.