Aim24 Care Wokingham

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.

This is the first assessment for this newly registered service. This key question has been rated 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 governance at the service.

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.

Leaders had a clear understanding of the immediate priorities for the service; however, this direction was not consistently understood or experienced by staff. While most staff told us they were committed to providing good care, their experiences of the leadership culture varied. Some said leaders were approachable and willing to listen, while others did not wish to comment or felt unable to share their views.

Following concerns previously raised by the local authority, the service had been issued an action plan requiring improvement. Leaders had engaged with this and had begun to address some areas, such as updating documentation and reviewing staff training needs. However, several key actions had not been completed within the agreed deadlines.

Overall, although leaders demonstrated a willingness to work with external partners and recognised the need for improvement, delays in meeting action plan targets and mixed staff experiences meant the service was not yet operating with a fully shared, cohesive or well communicated culture. Further work is needed to build staff confidence and develop a clearer, more responsive leadership approach.

Leaders were working to develop a clearer understanding of the context in which the service delivered care, treatment and support. They aimed to promote the organisation’s culture and values; however, this was not always demonstrated consistently.

People told us they had regular contact with office staff and felt comfortable speaking with them. However, most had limited awareness of the wider leadership team or how the service was overseen and reported little direct contact from the registered manager Staff also gave mixed feedback about the level of support they received from leaders. While some reported feeling supported and able to seek guidance, others told us this was not always the case.

An on call duty manager system was in place, but staff described varied experiences of how reliably calls were answered and how promptly concerns were responded to.

Overall, leaders were committed to making improvements and strengthening oversight. Further development is needed to ensure leadership is consistently visible, supportive and aligned with the service’s values, so staff and people experience a more cohesive and compassionate leadership approach.

People and their relatives told us they felt able to speak up and raise concerns, and that these were generally addressed appropriately. The service had a whistleblowing policy in place; however, staff feedback about raising issues was mixed. Some staff said they felt comfortable approaching leaders and believed they would be listened to, while others chose not to comment, which may indicate they did not feel fully confident to speak openly.

The provider demonstrated a commitment to promoting diversity and developing an inclusive and fair workplace culture. Policies relating to equality, diversity and inclusion were in place and reflected current guidance. Training records showed staff had completed mandatory equality and diversity training. These measures supported the provider’s aim to maintain an equitable working environment.

Governance arrangements were not effective and did not ensure the delivery of safe or high quality care. The provider did not operate reliable systems to identify and manage risk, maintain accurate and up to date information, or ensure that professional guidance was incorporated into people’s care plans. Although audits were being completed, they were of poor quality and failed to identify significant concerns. Several audits contained duplicated information, incorrect names, and conflicting or inaccurate dates, reducing their credibility and limiting their ability to drive improvement or provide assurance.

Care plans lacked essential clinical information needed to support people safely. For example, a person with a known choking risk had a Speech and Language Therapy (SALT) assessment completed in July 2025, however this had not been added to their care plan. The care plan was only updated following CQC intervention, and not through the provider’s internal governance processes. Although staff had access to electronic care plans, people and their relatives did not consistently have copies available in the home. This meant families were unable to understand the person’s assessed needs, monitor whether care was being delivered as agreed, or access essential risk information in the event of an emergency. This lack of accessible care planning limited involvement in care, reduced transparency, and increased the risk of unsafe or inconsistent support. Care plans were only provided to people after CQC involvement, which demonstrated reactive rather than proactive information governance.

Audits of care calls were ineffective. They did not identify concerns where staff attending double up calls were recorded as arriving at different times, or that a call documented as 100% completed had lasted only three minutes. These issues were not identified through the providers routine quality monitoring.

There had recently been an incident where several staff members informed the provider, they were unable to attend work. The provider was unable to cover all scheduled care calls and did not prioritise contacting the local authority’s out of hours team to escalate the issue. As a result, some care calls were missed, placing people at risk of receiving unsafe or inconsistent care.

Overall, the provider did not ensure effective oversight, accountability, or information management. Weaknesses in governance processes resulted in missed risks, incomplete clinical information, and ineffective audits. This lack of robust governance increased the risk of unsafe or ineffective care and demonstrated that the provider did not have sustainable systems in place to monitor, maintain, and improve the quality and safety of the service.

There were shortfalls in the provider’s partnership working with the local authority. The council reported that the provider had not consistently responded to emails and did not always supply the requested information within the agreed timescales. This impacted the local authority’s ability to carry out timely monitoring and oversight of the service.

When information was submitted to the council it was not always accurate or up to date. For example, some care plans shared with the council had not been updated before being provided as requested. This reduced the effectiveness of joint working and did not fully support collaborative decision making or continuity of care for people. Overall, these issues weakened communication between the provider and external partners and did not meet expectations for transparency, responsiveness and effective shared working within the community.

The provider and manager were motivated to work towards continuous learning and improvement across the organisation. They told us they had an been working with the local authority over a number of months to improve and had an action plan with areas of improvement, which in part had been completed. Although the provider was motivated to learn and improve the service for people, this is not what we found during the inspection. Their overall ambition was limited by the lack of effective risk and quality monitoring systems. This meant they might not always be aware of or recognise shortfalls to enable prompt improvement or embed learning.