The Business Centre

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

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider remains in breach of Regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Good Governance.

This service scored 36 (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 have a statement of purpose which provided details on the aims of the service, however this was not reflective of the care being provided, with the provider failing to have oversight of the effectiveness of the service or being able to make the necessary improvements to the management and governance of the service to become compliant with regulations. The warning notice stated we were not assured alerts were received and responded to or identified when a carer had not attended to a call or had arrived late. This was still what we found at this inspection and remaining in breach of regulation since 2018 which was a barrier to the service achieving the aims and direction indicated in the statement of purpose.

While people and family members told us the managers and provider were caring and compassionate, it was not always evident in how care was delivered. We found information that suggested staff were not always attending calls in line with people’s assessed needs. The provider did not fully understand the steps needed to ensure planned care was delivered in a way that was always compassionate to people’s needs and wishes. Decisions made by the management were not always reflective of what people had told them they needed. One person had their wishes and needs identified in their care assessments; however, the provider made changes which did not reflect the personal preferences expressed in the care records. This did not demonstrate and approach that was compassionate to the wishes of people receiving care.

Staff said they could raise concerns with the management team and relatives felt able to speak up and the provider listened. However, where people had raised preferences of how care was planned and delivered this was not always listened to. One person had support from staff whom they had previously expressly identified as not being appropriate to support them. This did not assure us people’s views were always considered and respected.

The systems to gather and consider people’s views had not identified the gaps and inconsistencies in care delivery that people and relatives we spoke with had raised.

A whistleblowing policy was in place and staff were aware of the policy.

The provider had a recruitment process and the staff files we reviewed did not identify any issues. There is a diverse workforce and an equality and diversity policy in place.

The provider did not have clear governance and oversight of the service. They did not always act in a timely way to respond to concerns or to take the necessary actions to ensure a safe and effective service. The provider had remained in breach of regulations for the past 5 consecutive inspections and had failed to make the necessary improvements to comply with 2 warning notices served by CQC in April 2025, meaning people continued to be at risk from a service that lacked improvement and did not have effective systems of management and governance.

Calls had continued to be missed or were unreliable and there was no effective oversight of people’s experiences. People continued to be at risk of their care needs not being met.

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.

Health and social professionals told us they did not always feel appropriate actions were taken in a timely way to address concerns. Insufficient improvement had been made to demonstrate the provider understood what actions were needed to work effectively with their partners in CQC and the local authority.

The provider did not focus on continuous learning and improvement across the service. They did not encourage staff to take creative ways of delivering equality of experience, or outcomes and quality of life for people. While the provider showed us what they understood to be the improvements necessary to meet the conditions of CQC enforcement, it was not sufficient to demonstrate lessons had been learnt from previous CQC inspections. The lack of effective systems, governance and management meant there was no drive to improve the safety of efficacy of the care and support being delivered. People continued to have poor experiences of care, with a lack of action to improve people’s outcomes.

The provider did not have oversight of how care was delivered. This meant opportunities to analyse and review the outcomes for people and to identify any themes and trends did not occur. Learning was therefore not identified or shared with staff. This meant improvements to the service and the care people received were not always considered or implemented.