Excellence Healthcare

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 remained 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 regulations in relation to good governance.

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, and culture. This was based on providing people with the best quality of life and care they could provide, understanding challenges and the needs of people and their communities.

The provider engaged with staff, people, their relatives and others important to them.

Relatives told us staff were kind and compassionate. Staff and management fed back to us passionately about the care being delivered to people and spoke fondly of the people they were supporting.

Staff understood the providers values for the service were to ensure people received the best care they could offer. Staff were complimentary of the provider and told us they felt supported by them. Staff meetings took place and provided staff with the opportunity to have their voices heard. A member of staff told us, “The manager is approachable and is always there for support and advice.” Another staff member said, “We are a small team, and this helps, we get to know other team members and communication is good.”

The provider understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. However, whilst the provider was committed and compassionate, there had been limited progress on embedding effective governance systems. This had impacted on the development of the service.

The provider was also the manager and was involved in the service on a day-to-day basis. They knew people, their relatives and staff well, and expected good quality support to be provided.

Staff felt supported in their roles, enjoyed their work and worked well together. One member of staff told us, “I enjoy my role, and I feel I work well with (person’s name) and work closely with their family too.” Staff told us the management team were always available for support and advice.

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

Staff told us they had regular contact with the management team which gave them the opportunity to give feedback or raise any concerns. This was through spot visits, team meetings and staff supervision. Comments from staff included, “I feel I can speak up and the manager would listen.” Another staff member told us, “I feel listened to, we asked about getting our staff rota/schedule sooner and this was responded to immediately.”

The provider had processes to inform staff how to whistle blow. Staff were able to raise concerns. The provider told us no recent staff surveys had been completed but this was something they were planning to do.

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.

There were systems in place for matching staff to people, for example, if a person preferred a male or female member of care staff. There were processes for staff recruitment and induction. Staff received training relevant to 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’s governance systems were not always effective. These systems had not enabled them to identify and address the shortfalls in quality and risk we identified during our assessment. Audits had failed to identify people’s care records and risk assessments did not always include all the information and guidance needed for staff to follow in relation to the management of specific risks. The providers audits of staff recruitment had failed to identify their recruitment policy was not consistently implemented and people were protected by safe recruitment practice.

Notifications were submitted to CQC as legally required. The provider had a system for monitoring incidents, some further work was needed to ensure lessons learnt from these were fully embedded. Relatives told us they were contacted for feedback and unannounced spot checks took place in people’s homes to check on the quality of care.

The provider responded positively to our feedback and told us improvements would be made; they told us they were taking steps to improve their audit and governance systems including installing an electronic monitoring system for care calls.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, the involvement of external health care professionals was very limited. There had been some contact with the district nurse team, and this was referred to in care records and acted on. They did however, work with local commissioning teams to support people with their care and support needs and these teams told us they had no concerns about people’s care.

The provider told us if referrals to health and social care professionals was needed, they would work with the person and their family. There were currently no health and social care professionals involved with people that we could contact as part of the assessment process.

The provider did not always focus on continuous learning, innovation and improvement across the organisation. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The provider was receptive to our feedback around areas of improvement, but they had not demonstrated sustained improvement. The provider had only limited interactions with professionals and stakeholders for learning and to help them understand best practice. Learning from incidents needed further development so there was robust evidence of a lessons-learned process embedded into day-to-day practice.

Staff confirmed they benefitted from regular spot checks and team meetings and received feedback about their performance, however there was no system in place for formally assessing staff competencies. This would provide the opportunity to ensure learning was embedded and future learning and development needs identified.