16 King Street Also known as O2 Care

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 newly registered service. This key question has been rated 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 the legal regulation in relation to governance systems.

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 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.

Policies and procedures were provided to guide staff in equality, diversity, and human rights, helping to promote good standards of care. Staff felt they were valued as a member of the team. We were told staff meetings were regularly held as well as the daily handovers, helping to keep them involved and informed about events within the service.

People were provided with clear information on how to raise suggestions and concerns about the service. As the service is small people had the opportunity to share ideas and raise concerns on a regular basis. Staff were seen to interact well with people during our visit. However, there were little meaningful, structured activities taking place providing people with opportunities both in and away from the home.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

Since registering in July 2024 there have been several changes in management at King Street. At the time of this assessment, the manager had only been in post several weeks. They had submitted their application to register as the manager to CQC. The manager was supported in their role by senior managers and a consultant, experienced within the mental health sector. The service requires a period of stability so that areas of improvement can be implemented and embedded.

The management team acknowledged areas of improvement could be made and demonstrated a willingness to address these so people received care and support that met their individual and complex needs.

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

Due to the size of the service, opportunities for people to speak with staff and managers was readily available. Procedures were in place to guide people and staff in raising any issues or concerns in confidence.

Staff told us they had opportunities to speak up and they would be listened to. Staff were aware of the whistle blowing policy and knew the procedure to follow. One staff member told us they would report issues to managers, adding, “I believe they would act promptly and if not, I would escalate externally to safeguarding board, CQC, or police.”

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.

An equal opportunities policy was in place. This outlined the providers commitment to providing equality of opportunity, diversity and following practices which are fair and lawful.

The team comprises of both male and female staff. Following feedback from staff the provider has been granted a sponsorship licence providing support and ongoing employment for those staff.

Staff meeting minutes showed work related issues were discussed by the team. Appropriate actions were taken to help promote their involvement and well-being.

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.

The service provides support for people whose primary needs are in relation to their mental health, along with a learning disability and autism. An application to remove a condition of registration preventing support for people with a learning disability had been submitted to CQC. The service needs to consider good practice guidance and relevant staff training to better support people with a learning disability and Autism.

A review of records showed audits and checks were completed in some areas such as, medication and health and safety. However, these did not explore all areas, nor identify the areas for improvement found during this assessment. For example; training and development in line with best practice, accurate and complete records, and systems to ensure people’s rights were protected.

A ’mock assessment’ had been completed internally. This identified improvements were required to care records and governance systems. However, this information had not been reflected in the homes business improvement plan. Governance systems needed expanding upon, providing clear oversight of all areas of the service, helping to better inform plans to develop and improve the service provided.

We reviewed the Statement of Purpose and provider website which detailed the services offered at King Street. These included support with daily routines as well as engaging in meaningful activities, building life skills in preparation for greater independence. However, we found little evidence this was being provided.

Policies and procedures needed to be reviewed to ensure information accurately reflected the service and relevant legislation so staff were clearly guided in their role and responsibilities.

The manager was aware of their responsibility to report specific events, such as safeguarding concerns, to CQC as required by law.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Further work was required to support people to engage with the local community creating meaningful opportunities for people to get involved, whilst ensuring their safety.

The provider was working collaboratively with other agencies to help identify improvements in areas of care delivery. The local authority told us a commissioning and quality review had been completed and an action plan was in place. We were told the service had needed some support, adding, “I have worked closely with O2 over the last few months and found they are very responsive and a genuinely caring service."

The provider did not always focus on continuous learning, innovation 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.

A number of management changes had taken place since registering with CQC in July 2024. A new manager had recently been appointed. System to support the management team in driving improvement were needed. The management team were responsive to feedback following this assessment and acknowledged the areas for improvement.

Governance and quality assurance systems needed expanding upon to help identify and evidence on-going and sustained improvements in line with best practice. A visiting healthcare professional spoke positively about working with the service. They said, “The level of engagement and willingness to adapt has contributed positively to the client's overall wellbeing.”