Vintage Revelations Gloucestershire

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 legal regulation in relation to good governance and notifying CQC of incidents.

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.

The provider was passionate about the service and the direction of the service. The registered managers and staff were enthusiastic about their role and supporting people. They told us the service aimed to provide high‑quality care for local people in their own homes, which focused on people’s individual needs. Systems were in place to ensure new staff understood the service’s values, policies and procedures.

Our assessment findings were shared with the registered managers. They confirmed their commitment to improve the quality of the service.

However, we found people’s experiences of the service did not align with the provider’s values. Some relatives and staff felt communication from the office was variable and they did not always feel listened to by the managers. One relative said, “Overall I am very satisfied, but some changes would be helpful at times.”
 

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

We were not fully assured the registered managers understood their roles and responsibilities regarding regulatory compliance to ensure the service delivered safe and effective care. Some staff felt the daily management of the service was not effective and they had to raise concerns with the director of the service to be heard. One staff member said, “I will go to the owner if I need to be listened to…… When I contact the owner, everything is sorted immediately though.” Relatives raised concerns about the management of the service due to ongoing issues with the promptness of people’s care calls and communication from the office and management team.

There were two registered managers in post who were supported by several key senior staff to run the management of the service, staff training and recruitment. We found the management team had a strong commitment and passion to providing a local care service. They worked well together and shared the provider’s vision and direction for the service.
 

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

The registered managers were approachable and had an ‘open door’ policy. Staff told us they were able to speak to the registered managers and felt they were listened to and had their views considered. Staff had opportunities to attend staff meetings and call the office to discuss any concerns relating to people who used the service or how the service was being run.

People using the service and their relatives said they had no hesitation contacting the office; however, some reported communication regarding returning calls could be improved.
 

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.
Staff spoke positively about the workforce culture of the service and told us they were valued and treated with respect.

The registered managers were mindful of staff’s personal backgrounds and individual circumstances. Staff said the leaders of the service were supportive and raised no concerns about discrimination or harassment.

The registered managers worked alongside staff delivering care to better understand challenges staff faced in their roles. Some reasonable adjustments had been made to support staff to carry out their roles.
 

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.

The provider and registered managers had failed to ensure their systems to monitor, assess and improve the quality of people's care were effective. The registered managers had implemented several quality systems, including running reports from the providers electronic care management system. However, these systems had not always been effectively embedded and sustained, as they had not identified the shortfalls we found during our assessment. We identified people's care plans were not always current or reflective of people's support requirements. The providers auditing system had not identified gaps and discrepancies in people’s care, risk and medicine records. This placed people at risk of receiving unsafe care. Systems to check staff’s daily notes had not identified changes in people’s care or the accuracy of the records of care delivered. For example, one relative said, “We did the care plan and there is paperwork here, but I see on the App that they have done things when they haven’t, and we have had to do it and a lot of the time we are almost too weary to do it.”

The analysis and recommendations from incidents were not clearly recorded in people’s care records. Some notifiable incidents had not been notified to CQC in line with the provider’s legal requirements.

People’s care call times and preferred gender of staff had not been effectively monitored to ensure people received their care calls on time by their preferred gender of staff. The provider had identified shortfalls found in the safe recruitment of staff when they transferred to Vintage Revelations, Gloucestershire under the ‘Transfer of Undertakings (Protection of Employment)’ (TUPE) framework from another employer however not acted on the gaps in staff checks in a timely manner.

We received mixed comments from people and relatives about the responsiveness of the management and office team. Some said they had seen an improvement and said, “I can speak to the office but to be fair if I have asked for changes they have done it.” However, others felt communication from the managers and office staff was variable. Relatives said comments such as, “When we have complained it’s ‘well we’ll try and get around to that’ but they don't really”; “I speak to the office and it’s ‘we’ll sort it’ but it never does and they don’t get back to you” and “The office is often hard to get hold of; they don’t ring you back.”

This meant effective systems were not in place to assess, monitor and drive improvement in the quality and safety of the services provided, including the health, safety and quality of the experience for people using the service.
 

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.

The registered managers stated they had developed links with local health and social care teams and had approved access to the GPs systems to help them understand people’s health needs and treatment. They said they contacted health and social care professionals for advice and guidance as needed. For example, they worked closely with the district nursing team and occupational therapist to help people remain in their own home.
 

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. They did not always actively contribute to safe, effective practice and research.

We identified through feedback from people and their relatives, the actions taken to resolve people’s concerns had not always been sustained. The registered managers recognised the need to develop their governance systems and improvement plan to ensure consistency in delivering good quality care.

However, the provider was committed to develop the service. They had invested time into national and local sector networks and events and had sponsored a team to attend national events to help drive best practice and innovation.

Further time was needed to implement and embed a service improvement plan and to develop practices.