Aspire Hub 3

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 good. At this assessment the rating has changed to 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.

This service scored 50 (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 did not have a clearly defined vision, strategy, or culture based on transparency, equity, equality, human rights, diversity, inclusion, and engagement. They did not always demonstrate an understanding of the challenges faced by people or the needs of their local communities.

Feedback from staff about the service culture was mixed. One staff member commented, “The quantity of staff is good, but the quality is not so good.” Another said, “I feel Aspire does care, but it has been difficult without a good regular staff team.” In contrast, another staff member stated, “I love my job and feel well supported.”

A stronger culture of listening and acting on feedback was needed to ensure that concerns raised by people and their relatives were not only heard but addressed in a way that led to measurable improvements. While new systems and processes were being introduced, further work was required to embed and sustain these changes effectively.

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 received mixed feedback in relation to the leadership and management of the service. A staff member told us, “I feel that we just hand over concerns, and we don’t hear anything after that.” Another staff member told us, “My managers are supportive and approachable. They give me time off for any family issues I might have." A relative who shared feedback on the management of the service told us, “I have good communication with the management team, I feel included and informed.”

The service managers were all relatively new to their role and were learning on the job, during the assessment process they were responsive to feedback and open and transparent alongside the registered manager. A staff member told us “[Name of registered manager] is helpful, and we have regular team meetings, however this was not the experience of all staff throughout Aspire hub 3, other staff told us we have only had 3 team meeting this year and when we do nothing changes.”

We found there was inconsistent oversight of the service. The management structure in place and their responsibilities did not work effectively. The registered manager told “overseeing so many homes is challenging when they are so widespread across the city.”

The provider did not consistently ensure people could speak up and that their voice would be heard. Staff reported feeling comfortable raising concerns with the registered manager, with one staff

member stating, “I have and will continue to raise concerns; however, I do not always feel listened to.”

Feedback from people and their relatives was mixed. While all felt they could speak up, not everyone believed their concerns were consistently listened to or acted upon. One person commented, “I can speak to staff and management anytime I want to and feel that things are acted on.” However, another expressed frustration, saying, “I feel I raise things, but it depends on who you speak to with regards to what is done.” These contrasting views highlighted inconsistencies in how feedback was received and responded to across the service.

We received mixed feedback regarding team meetings with some staff in some areas stating they had these regularly and others stating that these are few and far between and nothing changes following meetings.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Although staff felt that they could speak up they did not always feel that action was taken to improve the experience of staff. A staff member told us, “I don't think managers have always dealt with it appropriately.” Another staff member told us, “I have raised concerns; however, I do not feel that management want to deal with it.”

Feedback from people and relatives was mixed. One person said they felt they could speak with the management team at any time and that what they said would be listened to and action taken, whilst a relative told us that although their loved one had a good life and was supported well to do the things they liked, their suggestions to improve things like communication were not always acknowledged.

The provider did not always maintain clear responsibilities, defined roles, or effective systems of accountability and governance. They did not consistently act on the best available information about risk, performance, and outcomes, nor did they always share this securely when appropriate.

Although systems and processes were in place to assess and monitor the quality and safety of the service, local oversight arrangements were ineffective. This meant the provider failed to identify and address the shortfalls we found during our assessment, and improvements were not implemented as required.

Audits carried out by the service were not robust. While audits were completed, they were either too infrequent or failed to identify gaps, inconsistencies and a lack of appropriately detailed records. As a result, these tools were not effective in monitoring or improving the quality and safety of care.

Our assessment identified significant governance failings, resulting in a regulatory breach. The provider did not have sufficient governance and oversight arrangements to ensure systems and processes were effective in assessing, monitoring, and improving the quality and safety of care and support for people using the service.

The provider did not consistently fulfil its duty to collaborate and work in partnership to ensure services operated seamlessly for people. Information and learning were not always shared with partners, and opportunities for joint improvement were missed.

Both the provider and the registered manager failed to maintain effective oversight, learn lessons, and implement changes to improve the service. However, the registered manager demonstrated a strong commitment to addressing the shortfalls identified by CQC and to developing the service, so it meets the needs and wishes of the people it supports.

The provider did not consistently prioritise continuous learning, innovation, or improvement across the organisation and local system. They did not always encourage creative approaches to delivering equality of experience, outcomes, and quality of life for people, nor did they actively contribute to safe, effective practice and research.

Although the provider, managers, and staff recognised the importance of learning from incidents, audits, and feedback as opportunities to improve the service and people’s quality of life, we found that audits were not being used effectively to drive learning or strengthen quality assurance processes.

Further work was required to embed a culture of learning, improvement, and innovation at a local level. However, the registered manager and management team demonstrated commitment to addressing these shortfalls and driving positive change.