Our 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.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 64 (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.

There were processes in place to ensure the service promoted a positive culture for people they supported and staff. The registered manager told us about the direction and culture of the service. They told us their aim was to, “Not be the same as others, have time for people and deliver a good service.”

Not all leaders understood the context in which the provider delivered care, treatment and support.

There was a lack of understanding of the importance of documented governance systems from the leaders. Due to the small number of people they were currently supporting, this did not impact on people and there was oversight of the care people received. The registered manager acknowledged the system would need to improve and be documented as the service grew.

People were happy with how the service was managed. One person told us, “I am totally satisfied with the care I receive”. Care staff were aware of their roles and responsibilities and when they needed to escalate concerns.

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

There was a whistleblowing policy in place. Staff we spoke with were aware of these procedures and the action they needed to take if they had concerns.

The provider valued diversity in their workforce.

There were procedures in place to consider staffs’ individual needs, this included considering staff’s diverse needs and treating all staff fairly and equitably. Staff raised no concerns with how they were treated.

There were not always documented systems in place to make changes and identify areas of improvement.

Since our last inspection the registered manager had introduced a range of audits/checks on people’s care, this included a review of the medicines administration records to ensure medicines had been administered as prescribed and a review of the daily notes. However, these were not always documented to show they had taken place. Staff were able to confirm to us these reviews were taking place. The registered manager acknowledged these would need to be documented and offered us assurance as to how these would be completed in the future.

There was an electronic system in place that was used to monitor the care people received. This was regularly monitored by the registered manager to ensure care and medicines were delivered on time and in the correct way. The system in place was live, and alerts were sent to the registered manager if a concern arose. This system was monitored at all times. This meant any concerns or delays could be managed in a timely manner.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

There were systems in place to ensure the provider worked in partnership with other agencies. The registered manager gave us examples where they had made referrals to other professionals for advice or support.

As part of this assessment, we asked the Local Authority for feedback, they had no information to share with us.

The provider did not always focus on continuous learning, innovation and improvement across the organisation.

There was a lack of documented governance systems in place to ensure any identified concerns were acted on in order to drive improvements within the service, which meant learning opportunities could be missed.