Dale Care and Support Ltd Also known as Heritage Healthcare-Rochdale

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.

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.

Improvements were needed to ensure governance was more robust and effective in managing the day-to-day quality assurance of the service. This would help ensure actions identified in quality audits were followed through and embedded into the service.

Management had meetings with staff to discuss the expectations of the organisation and any concerns they had. Staff undertook a range of training to help ensure procedures were followed. There was regular communication between staff so that they could share their experiences and learn from one another.

The provider welcomed and supported an open culture which was supported by staff feedback to us. Staff were confident to identify poor practice and told us concerns would be acted on. People told us staff were kind and compassionate.

Leaders did not always have the skills and experience to lead effectively. Systems and processes were not always fully understood by senior staff to be entirely effective. Governance systems did not always ensure leaders were knowledgeable about issues and priorities for the quality of services.

The registered manager had not been present at the service for a number of months. A member of the office team had stepped up to the position of deputy manager at the time this assessment took place.

Staff were positive about the leadership of the service and felt the managers were caring. Staff told us they felt listened to. One staff member said, “The door is always open, I know the right person to speak to and know any issue would be sorted.” The provider delivered care to people regularly and worked alongside the staff team. However, they did not always have effective oversight of the service.

Individual staff supervision and group team meetings were used by the provider as a platform to ensure that all staff felt able to raise any concerns they might have. However, spot checks and supervisions were not always completed regularly.

The provider had the relevant policies and procedures for ‘freedom to speak up’ including a whistleblowing policy and procedure.

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

Staff felt they could speak up.One staff member told us “Management listens to everything and deals with issues well.”

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. Systems and programmes were in place to support staff inclusion and needs. The provider had recruited a diverse workforce. Staff had completed training in equality and diversity.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

Audits for medicines and care planning were in place and had been carried out, but they were not always robust enough to be effective.Audits did not cover some of the most important aspects of the area being scrutinised such as why medicines had not been administered. None of the audits identified the issues we found during the inspection.

The deputy manager shared plans to make improvements based on our feedback.

The provider had systems in place to monitor the service. However, these were not being used effectively to ensure actions were taken and recorded when incidents were identified. For example, the system had identified where people’s medicine administration records were not completed by staff. The system required the deputy manager to investigate, take action and document the outcome on the system we saw this had not been completed on several occasions and we could not be assured the medicines oversight systems were effective.

The provider understood and carried out their duty to collaborate and worked in partnership, so services worked seamlessly for people. People and their families told us they received effective care and that their needs were met.

Staff and the management team told us they worked in partnership with other organisations such as healthcare professionals and commissioners to support the care provision. Records showed evidence of this joined up work.

The management team attended a local provider forum and sector webinars to share and improve their knowledge.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research. A lack of oversight and governance had impacted on their ability to do this.

Leaders understood how to make improvements but lacked a consistent approach measuring outcomes and monitoring impact. The provider took all concerns raised seriously and responded to them on an individual basis. They had investigated them but it was not clear if a thorough root cause analysis had been completed to monitor for patterns and trends to minimise the risk of further recurrences.