Farecare Gloucestershire 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.

At our last assessment we rated this key question Inadequate. 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.

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 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 understand the challenges and the needs of people and their communities.

Improvements from repeated shortfalls in governance and record‑keeping from earlier assessments had been slow to be addressed. This indicated the provider did not fully understand or act on the challenges facing the service.

Overall, staff interactions with people were caring and positive, these strengths were not supported by a consistent organisational culture focused on learning, accountability and improvement. We saw evidence that improvements were beign implemented, however, further time was needed to embed new processes and practices to ensure a culture of continuous improvement.

The leadership team knew people well and were committed to providing quality care. There was a clear and well-defined management structure, which included a manager, an office manager and a care co-ordinator. The manager told us, “We acknowledged how management haven't had a lot of experience in the sector, but we're committed to learning.” The manager had recently submitted their application to become the registered manager of the service.

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

The manager told us about improvements made since the last inspection. They said, “We have a whistleblower policy staff all have access to and they have training. There is a feedback box in the other room where staff can raise anonymous complaints. This is something I've put in since the last inspection as it was mentioned there were some concerns with everyone in the office being related.” Staff told us, “I feel encouraged to speak up. You can be blunt and its ok. I don’t have a good way with my words, but management still listen. They always act on what I have said” and “Management encourage you to speak up but if you don’t feel you can, you can hand write concerns anonymously and drop it in a feedback box which is in a room next to the main office, so managers can’t see you do it. There is always feedback to the entire team in the group message chat group.”

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 had completed equality and diversity training, which helped reinforce the organisation’s commitment to inclusion. Staff consistently told us they were treated equally and felt valued by the management team. One staff member shared, “I don't have any concerns about how I'm treated as an employee.” Another staff member said, “The manager is approachable, reassuring, and committed to maintaining high standards of care. All of the office staff provide clear guidance and encourage open communication among the staff.”

These comments reflected a positive workplace culture where staff felt empowered, respected, and engaged.

The service 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.

The provider needed further time to embed new systems in place to monitor the quality of the service. Audits had only recently been implemented and there had not been enough data collected to show effective use of the audits. Audits are an essential process which enables managers to identify and address shortfalls or areas for improvement.

The manager reacted positively to concerns raised during the inspection, however governance systems needed strengthening to ensure staff identified and managed risks promptly and used robust quality assurance processes to drive continuous improvement.

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.

The service had developed partnerships with various organisations and the local community through the district nursing team, the local authority, and through good links with health professionals. We saw evidence of the service making appropriate referrals and liaising with social workers and other professionals to enable seamless care delivery.

The provider 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.

Further work was required to strengthen processes for identifying areas where improvements were needed, particularly in relation to care records, risk management and governance. At this inspection We were not assured areas for improvement and opportunities for learning would always be consistently identified and addressed in a timely and effective manner,, however, the manager and leadership team demonstrated strong commitment to making the necessary improvements.

A proactive approach to continuous improvement is essential to ensure risks are mitigated, governance systems remain robust, and best practice is embedded throughout the service. Without this, there is a risk issues may persist or reoccur, impacting the quality and safety of care provided.