Pembroke Care (Reading) Domiciliary Services

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 75 (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 promoted a culture focused on delivering safe, person-centred care. Staff demonstrated an understanding of the values of the service and the importance of treating people with dignity, respect and compassion. The management team was receptive to feedback and demonstrated a commitment to continuous improvement. Staff understood the needs of the person they supported and spoke positively about enabling them to maintain their independence and wellbeing. Systems were in place to gather feedback from people using the service and their representatives. Staff feedback was gathered through meetings, open surgery sessions, and 6 monthly staff surveys. This feedback was used to support service development and continuous improvement.

The management team demonstrated the skills, knowledge and experience required to oversee the service. They were open and transparent throughout the assessment process and responded promptly to requests for information.

Staff generally spoke positively about the support they received from managers and told us they felt able to approach them for advice and guidance when needed. Records showed staff had opportunities to raise concerns, share feedback and discuss issues affecting their role through meetings and supervision sessions.

While a small number of staff raised concerns about aspects of management practice, these views were not consistently reflected in feedback from other staff. We found no evidence these concerns had a wider impact on the quality of care provided or the overall culture within the service. Leaders promoted an open and supportive culture and demonstrated a commitment to maintaining and improving the quality of care provided. Governance systems had improved since the previous assessment and provided management with greater oversight of quality, safety and service delivery.

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

Staff were encouraged to raise concerns and understood how to do so. Policies and procedures supported whistleblowing and the reporting of concerns.

Staff told us they would feel comfortable approaching management if they identified unsafe practice or wished to discuss concerns. Regular supervision and staff meetings provided opportunities for feedback and discussion. Feedback from staff was generally positive, and discussions evidenced a culture of openness and transparency. Staff understood how to raise concerns and felt able to do so, with systems in place to ensure concerns and feedback could be discussed, addressed and used to support continuous improvement.

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. Policies and procedures supported an inclusive culture where everyone was respected, and differences were celebrated.

The provider had systems in place to monitor the quality and safety of the service. These included audits, spot checks, reviews of incidents and accidents, staff supervisions and feedback from people and relatives using the service.

Information gathered through governance processes was used to identify learning opportunities and drive improvement. Action plans were developed where required and progress was monitored. The provider maintained oversight of key risks and worked with relevant professionals where appropriate. Required notifications had been submitted to CQC and appropriate referrals were made to external agencies when necessary.

Overall, governance arrangements provided assurances the service was being monitored effectively and improvements could be identified and acted upon.

The provider worked collaboratively with health and social care professionals to help ensure people received coordinated care and support. This included engagement with GPs, community healthcare teams and other professionals involved in people's care.

Feedback from professionals was positive and indicated the provider was responsive to advice and willing to work in partnership to improve outcomes for people. Information was shared appropriately to support continuity of care and ensure people's needs were met.

The provider sought to learn from incidents, accidents, complaints and feedback. Lessons learned were discussed with staff and used to improve practice. Regular quality assurance audits reviewed areas of service delivery, including incidents and accidents, to identify themes, trends and opportunities for improvement.