Gogomadu Cares

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 Good. 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.

The service was in breach of legal regulation in relation to good governance.

This service scored 43 (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 always 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.

The provider was approaching their tenth year in operation. The provider told us about the origins of the organisation, but also their vision for providing people with the best possible care and support, now and in the future.

We found that leaders vision did not always translate into a consistent approach to delivering a person-centred service. We found that further work was required to clearly define the strategic direction of the service in relation to governance and assurance and how this would be strengthened.

We assessed the service against the ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We found the provider did not consistently meet the principles of this guidance.

Feedback we received during the assessment in relation to the registered office being in the grounds of a supported living service suggested this was impacting on service delivery.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

At the time of the assessment there was a manager registered with the Commission who was also the provider’s nominated individual and a director of the service.

The registered manager was supported by a leadership team consisting of a care manager, training manager and HR and administration manager.

Feedback we received was generally positive about the leadership team, particularly the availability of the care manager and knowledge and professionalism of the HR and admin manager. For example, a relative told us, “The care manager responds quickly when I email her, I do feel I can contact her."

However, further work was required to strengthen leadership capability, clarify responsibilities, and ensure all leaders were equipped with up-to-date knowledge of relevant regulation and best practice to drive improvement and deliver high-quality, person-centred care.

We shared our feedback in relation to our findings during the assessment. Leaders of the provider were receptive to our feedback and told us they agreed the roles and responsibilities of the leadership team needs to be redefined.

People felt they could speak up but we were not assured their voice would always be heard and lead to meaningful change.

The provider had a whistleblowing policy in place and staff told us they were able to speak up and they felt the provider would listen. However, we found there was no systems or processes in place that demonstrated staff feedback would lead to meaningful change. For example, there had been no employee engagement survey.

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 was accredited as a disability confident committed employer.

However, the policies we reviewed did not contain adequate detail and did not reflect current legislation or best practice guidance. For example, recruitment, safeguarding, infection control and equality diversity and inclusion.

Policy reviews that had taken place were not effective. This meant we were not assured staff had adequate guidance or that staff would be clear about their right or protections in relation to equality, diversity of inclusion.

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.

The provider had implemented a range of formal quality frameworks and monitoring systems, including accreditation to ISO 9001 and ISO 45001 standards. They also completed a variety of internal audits covering areas such as medicines management, staffing, spot checks, health and safety, call monitoring, and care delivery performance. However, these governance systems were not effective.

The provider’s processes for assessing, monitoring, and improving the quality and safety of the service had failed to identify significant shortfalls identified during this assessment. For example, in relation to recruitment, medicines, staff training, and care planning.

There was some evidence of team meetings taking place; however, these were not sufficiently robust to demonstrate a structured approach to driving improvement or learning across the service.

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.

The provider demonstrated some engagement with partnerships and the wider community.

For example, they were a member of the Skills for Care registered manager network for Northamptonshire and had links with community organisations, including fundraising for Cransley Hospice and involvement with local and national groups.

We founds that partnerships were not consistently used to drive improvement in the quality of the service. For instance, a recent local authority monitoring report had highlighted the need to follow Schedule 3 requirements in relation to safe recruitment practices. At the time of our assessment, the provider had not taken appropriate action in response to this guidance.

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 demonstrate they had a proactive approach to learning, improvement and innovation.

For example, learning from recent CQC assessment at another service operated by the provider and overseen by the same registered manager had not translated into meaningful improvements at this service.

The provider did not have a service improvement plan or any formal method to demonstrate learning, improvement and innovation to deliver meaningful change.

This meant we found similar shortfalls at this service such as medicines management; staff recruitment; delegated healthcare tasks; staff competency checks; risk management; care records; monitoring and audits.

We found the provider’s systems and processes had not been maintained to reflect current regulation or best practice guidance.

The provider needed to consider how to strengthen their governance processes to enable learning, improvement and innovation, including the introduction of an effective service improvement plan.

We shared our feedback in relation to our findings during the assessment. Leaders of the provider were receptive to our feedback and told us throughout the assessment about plans they had to make improvements.

We will check on the implementation of these plans at our next assessment.