Body&Soul Assistance, Admin.

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 stayed the same. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of legal regulations in relation to good governance and fit and proper persons at provider and registered manager level.

This service scored 32 (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 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.

There was a lack of engagement regarding organisational culture and core values. The provider failed to demonstrate that regular supervision and team meetings were used to reinforce the values of the service.

Staff expressed a pride working for the service and there was a genuine focus on providing person-centred care. However, key governance gaps and incomplete monitoring records indicated cultural expectations were not consistently embedded across the service.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively.

The provider and the registered manager were the same person. There was no other managerial or administrative support. We found the provider and registered manager was not able to demonstrate the skills and knowledge to be able to manage the service safely and effectively. There was no evidence they had undertaken recent training to ensure they were competent to manage the service and deliver training to staff. The provider could not evidence how they actively sought staff feedback or created consistent opportunities for engagement beyond informal conversations.

The provider had failed to submit Provider Information Returns (PIR) for the last 4 years. A PIR is information providers send to CQC about what the service does well and improvements they plan to make. After our last assessment we requested the provider submit an action plan to identify how they were going to make the required improvements. They did not submit an action plan. This meant they were not able to demonstrate a good understanding of their legal responsibilities under their registration. The service was rated inadequate in the well-led key question at our last assessment and there had been no improvements.

However, staff told us the registered manager and provider were approachable, and they thought the service was well managed.

People did not always feel they could speak up and that their voice would be heard.

Staff told us they felt able to speak up if they had concerns. However, the polices in place did not support this effectively. The whistleblowing policy had not been reviewed since 2018. There was no clear guidance or structured processes in the policy as to how staff could raise concerns either within the service or externally. This was further compounded as the registered manager and the provider were the same person.

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.

The provider employed a diverse staff team. Human resource policies were in place, but they had not been recently reviewed to ensure they contained up to date information and reflected changes in legislation and guidance. The service lacked structured systems, policies and processes to actively support and develop an inclusive workforce. This was further evidenced by the lack of professional support and gaps in training for both the provider and staff. Governance shortfalls meant the provider could not demonstrate how they created an inclusive environment where staff felt supported and treated equitably. However, we did not receive any concerns from staff.

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.

There was no evidence of audits or checks. The safety and effectiveness of the service had not been monitored. There were no care plans or risk assessments in place for people, and the quality of documentation was poor. Polices were basic and there was no evidence they had been recently reviewed. Documentation to assess key areas of risk were not in place. The provider had also been non-compliant with audit requests from the commissioning authority.

The registered manager told us they experienced difficulties completing records due to their disability. However, they had not ensured appropriate adjustments or support arrangements were in place to enable them to fulfil the requirements. This meant essential records and management processes were not completed or effectively overseen. These concerns were clearly highlighted at our last assessment and there was no evidence of any improvement. This meant the provider continued to be non-compliant with the regulatory requirements.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

During our assessment we found the service did not routinely share information or learn from health and social care providers. The provider had not met required improvements highlighted by the commissioning authority. The provider worked in isolation from the wider professional network, which meant they did not always benefit from feedback and industry learning. This approach led to persistent shortfalls in the safety, quality, and overall governance of the service.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider did not foster a culture of learning and improvement. Most of the staff training was delivered by the provider, and we were not assured this was robust or met current best practice guidance. There was no evidence of innovation or improvement planning. The shortfalls we had highlighted at our last assessment had not been addressed and additional regulatory breaches were identified, which highlighted the quality and safety of the service had deteriorated since our last assessment.