Conscience Care Limited

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 since its registration. 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 provider was in breach of legal regulation in relation to the governance and oversight of the service.

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 service did not always have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always ensure these values were adopted into practice.

Systems and processes were not always established to ensure the service understood their direction. For example, this meant they did not always have clearly defined outcomes set for the service and therefore did not identify the shortfalls we found during this inspection. Although staff told us they worked as a team and were supportive of each other, there was limited direction. We discussed this with the provider who understood the need to establish a clear direction to always ensure safety, quality and improvement.

Leaders did not always understand the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation as this had not been clearly defined. The provider did not always have the understanding and oversight to lead effectively.

The provider did not always share an understanding of the risks and issues facing the service and was not always clear about their responsibilities. For example, the provider had failed to identify the reporting of incidents, risks, issues and concerns was unreliable or inconsistent. We raised this with the provider during the assessment, and they informed us about proposed improvements.

However, we did receive positive feedback from staff about the compassionate approach of the management team. Some of the comments were: “The provider is kind, supportive, and easy to talk to. I feel confident in their leadership”, “I trust their leadership”, “They are approachable, supportive, and committed to ensuring high-quality care for both clients and staff.”

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

People and their relatives told us they were happy to speak with staff, the provider to address any concerns. Staff felt comfortable raising concerns, they knew how to speak up and had confidence they would be supported. The provider told us they dealt with any issues and concerns to ensure they were fully addressed.

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 told us they felt included as part of a team. Staff were complimentary about the senior staff and approach of the provider. A staff member said, “The provider understands the difficulties we might face and tries as much as possible to minimise or remove them completely.Our wellbeing is important to them.”The provider’s policies and procedures were all underpinned by equality and inclusion.

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, or share this securely with others when appropriate.

Governance, management and accountability arrangements were not reliable, consistent or operating effectively. Quality assurance arrangements were not applied consistently and were ineffective. For example, audits were not carried out as planned, this meant the provider did not understand how their service was operating and opportunities to plan were missed. Processes were not in place to ensure sustainable and dedicated management of the service. Oversight systems were not in place, including both at location and provider level. We discussed this with the provider who told us they had made plans to improve the oversight and governance systems within the service.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider sought to work with others, including external professionals. People’s support needs were met and where necessary referrals had been made to external health and social care professionals such as, social workers and the GP. The provider understood the importance of partnership working and sought to increase this within the service.

The service 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.

Systems and processes to ensure the service identified areas for development and continually worked to improve outcomes were not always established. Audits carried out to monitor the quality and safety of the service were inconsistent, repetitive and often incomplete. We identified several audits of the service which were incomplete or inconsistent and not carried out since 2023. Therefore, there was no opportunity to use the information to drive continuous improvement. For example, the service had sought feedback from people, relatives and staff but this had not always been used to shape the service and inform change. We discussed our findings with the provider, and they told us they were accepting of our findings in relation to the shortfalls. They told us they were working to establish systems for improved management oversight and learning, along with strengthening of the overall governance systems.