Sinai Care Solutions 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 requires improvement. At this assessment the rating has remained 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.

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 provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The registered manager told us they had a vision for the service and when new staff were recruited, they were told what the expectation of good care was. The registered manager told us, “We want to provide the best care for people.” Staff were passionate about the people they cared for. Staff told us they felt supported by the management team. Regular supervisions, training, reflective practice and an effective induction helped to ensure staff felt supported and equipped to carry out their care roles. Staff also told us they felt they worked well as a team. The management team operated an ‘open door’ policy where people, relatives and staff could speak to them at any time to ensure there was an open culture where concerns could be raised and acted upon.

Not all leaders understood the context in which the provider delivered care, treatment and support. The registered manager did not always have effective oversight of the service to identify and lead change. For example, effective action had not been taken to address all the medicines safety concerns identified at our previous inspection. However, the management team were open, honest and responsive to our findings throughout our assessment and were aware of the improvements needed to systems and processes to improve the quality of the service. People, relatives and staff all felt the registered manager was visible, approachable and were available to them. Staff also told us the registered manager was caring and listened to the staff. Staff told us how they were supported as employees and encouraged with their own development.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.The registered manager told us that if staff raised concerns, these were addressed and the staff team was made aware to ensure learning was in progress. The provider had a policy in place to support staff in raising concerns, allowing them the freedom to speak up and whistle-blow. The policy gave guidance to staff on how to raise concerns and assurances that concerns would be taken seriously and investigated appropriately. Staff confirmed they were aware of the policy and felt confident to speak, if required.

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. The provider had a policy in place to support equality and diversity. The policy set out to ensure all staff worked in an environment which was free from harassment and discrimination. The policy set out how staff would receive equal treatment regardless of their protected characteristics in all aspects of their employment.

The provider did not have effective oversight systems in place to provide good governance consistently and did not always have clear responsibilities, roles and systems of accountability. Although systems were in place to assess and monitor the quality and safety of the service, further improvement was required to ensure compliance with regulations. There were some audit systems in place to check on the quality of the service, however these were not always effective in identifying areas for improvement and driving change. For example, medicines audits failed to identify the absence of 'as required' protocols. The body map audits stated body maps were being done however, we saw this was not always the case. These were both concerns that were identified at our last inspection, therefore effective action had still not been taken to address these concerns. Care plan audits did not identify that 1 person had conflicting information relating to a health need which placed them at risk of unsafe and inconsistent care. We also found the provider did not always notify us of reportable events as we identified 2 safeguarding concerns that had not been reported to us as required. Following our feedback the registered manager completed the required notifications for these 2 safeguarding concerns.

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. Partners told us the provider worked in collaboration with other professionals such as social workers, the brokerage team and health professionals.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. There were a range of monitoring and audit tools to assess and monitor the delivery of care and support to people. However, the audits did not identify all the concerns mentioned in the report. However, the provider was responsive and open with the assessment process; they listened to our recommendations and demonstrated a willingness to learn and improve.