My Pillar 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 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 64 (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. The provider had a strategy in place which set out to provide person-centred care which aimed to deliver holistic support to people enabling them to live with dignity and independence. The registered manager told us how they were committed to ensuring they provided high quality care to meet individual needs. Staff told us they worked to ensure people received person-centred care. People told us they thought the service was well managed and they felt supported by the management team and staff. A person told us, “I do think the service is well managed. The registered manager visits me often and if I am unhappy about anything they do their best to rectify it. They make sure I have appropriate support.” A relative told us, “The registered manager is approachable, and I live quite a distance from [person’s name], and they keep me updated on a regular basis.” People and relatives told us the staff working with them were always happy and seemed content in their role. A person told us, “The staff often have joke with me and are never really down.” Staff also confirmed they were happy in their role. A staff member told us, “The company are quite good. We have good communication here it is what makes the difference it is brilliant.”

The provider did not consistently demonstrate they had the skills, knowledge, experience to maintain effective oversight of the service. This meant the leaders had not always taken effective actions to identify improvements needed and take action. For example, we found improvements were needed to medicine administration, risk assessment, care planning, reviews and consent. The provider had identified some of these concerns, but action had not yet been taken to address them. The leadership team were, however, keen to learn and sought opportunities to make improvements. The registered manager was open to the feedback from the inspection and shared with us how they would seek to improve oversight of the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was a policy in place to support staff to raise any concerns. Staff told us they were comfortable raising any issues with the registered manager and others on the management team. Staff understood other avenues open to them to share concerns about the service if they were worried and demonstrated a knowledge of the provider’s policy. The registered manager told us they had regular discussions with staff and felt confident staff would raise concerns 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 an equality and diversity policy and procedure in place. The policy worked to ensure the provider embraced the principles of the Equality Act 2010 and ensure everyone was treated fairly taking account of any protected characteristics. Staff told us the registered manager ensured they were well supported.

The provider did not always ensure the governance and oversight systems were used effectively to identify information about risk, performance and outcomes. The provider had systems to monitor and ensure people received their medicines as prescribed. Checks were done daily to ensure people had received their medicine and records were completed. However, where issues had been identified with medicines administration records and actions taken to ensure people had received their medicines, the outcome was not recorded in the electronic system which meant the monthly reporting to look for trends was not being fully utilised. The registered manager told us the system was new and not yet fully embedded. Since the inspection the provider confirmed they have requested additional training from the electronic system provider to ensure they can maximise the use of the medicines administration reporting function and make improvements to medicines oversight. Other governance and oversight systems were in place and operating effectively. For example, there were systems in place to check on the quality of the care people received.

The provider worked with other agencies to ensure people’s needs were met and shared information with partners as required. The registered manager told us they worked in partnership with a range of health and social care professionals to support people. They described working with individual health and social care practitioners to provide packages of care to meet peoples needs, including taking part in multi-disciplinary discussions about peoples care needs and how to successfully meet them. Staff also confirmed they were engaged in conversations with other professionals to provide people’s care. One staff member told us, “We have good relationships with other health professionals, for example we work with the intensive support team quite closely to support some people.” This meant the provider worked in partnership to support people.

The provider’s systems did not always ensure learning was considered when incidents happened. An audit tool was in place to look for themes and trends, however this was not being used at the time of the inspection. The registered manager confirmed following the inspection, further training was being arranged about the audit system and this would be introduced. Other learning processes were in place and embedded. For example, the registered manager told us how they worked with local organisations including the local authority and the West Midlands Care Association in order to identify areas where improvements could be made to the service. They also described how they used people and relatives feedback shared with them about the service as a tool to make improvements.