Provision Care Ltd

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. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good.

At the last assessment the service was in breach of legal regulation in relation to governance and oversight of the service. There was a lack of robust and effective quality assurance processes in place to monitor the quality of the service. At this assessment enough improvement had been made the provider was no longer in breach of regulation.

This service scored 75 (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’s vision and values were demonstrated to all who encountered the service. For example, staff meeting records provided them with opportunities to share their feedback and ideas together with the registered managers commitment to exposing people to an open and transparent service. One person told us, “The service has a good culture.”

The registered manager told us their vision was to grow the service slowly and pursue this by demonstrating to other stakeholders that future packages of care that may be sought from them confirmed the registered managers direction they are driving the service to was both realistic and achievable. People were provided with a service user guide that supported them to fully understand how their expectations could and would be met.

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

This was demonstrated by their commitment to improve aspects of the service following our previous assessment. They had accepted the shortfalls we had identified and submitted the required action plan to lay out how they would make the necessary improvements. This action plan was tested at this assessment, and we found the necessary improvements had been made and sustained.

They had incorporated other systems to achieve this including moving away from paper records to electronic ones. We saw how some shortfalls had been overcome when we reviewed the effectiveness of the system against some of the previous shortfalls such as medicines management records.

One person we spoke with shared their views and experiences on the registered managers capabilities. They said, “[Manager] is capable and experienced. Throughout the time I have received care they lead their staff team by example, and I receive good care from them. As my needs have changed, I have required more specialist support, and they have made sure the staff have the training necessary to continue to support me safely.”

Staff spoke positively about the support from the registered manager. They all said the registered manager was ‘considerate’ and ‘supportive’.

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

Staff said they were well supported and encouraged to share any concerns and make suggestions during staff meetings, handovers, and during supervisions and appraisals. They confirmed the registered manager had an open-door policy and made themselves available 24 hours a day if they needed to contact them. One staff member told us, “Absolutely! I am encouraged to speak up and I feel listened to and valued and can contact the manager at any time.”

Staff confirmed they understood whistleblowing and had access to the providers policy. They said whilst they had not had cause to use it, they would if they needed to.

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 registered manager had fostered an inclusive work force. Policies protected staff’s human rights and working conditions.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

At our last assessment we found the provider needed to make improvements to their governance systems and processes. At this assessment we found notable improvements had been made and been sustained over time. There was a system of audits and quality assurance covering all aspects of the service. This ensured the service was continually monitored to ensure sustainability could be maintained.

All notifiable incidents that had occurred in the service had been sent to CQC and local authorities appropriately and timely. We did direct the registered manager to our website for further clarification on some notifiable incidents and the context in which they needed to be sent. The registered manager undertook this at the time of the inspection based on our feedback.

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. One person told us, “I have health and social care organisations involved with my care. There is good communication between Provision Care and them. The manager is always involved in reviews of my care and uses staff’s feedback to support the review.”

Feedback from healthcare professionals and agencies showed communication with the service was positive and solid partnership working was in place.

The provider had and continued to focus on improving the service and learning from previous experiences. This was evident from improvements made to the quality of the service following our previous assessment. Equality was respected with experiences and outcomes at the forefront of the service to provide a service and good quality of life to people.

The provider was attempting to establish local links with commissioners as they sort to develop the service further.