Northamptonshire Domiciliary Care Agency

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 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 service was in breach of legal regulation in relation to good governance. Systems in place were not robust enough to assess, monitor and improve the quality and safety of the services being provided to people. Audits completed were ineffective. Systems and processes in place did not support learning and improvement.

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 not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

We received mixed feedback from staff about working at the service. The provider had a vision and a set of values (passion, inclusive, brave, positive, and kind) that were known by staff working in the service. However, a staff member told us, “I used to feel proud to work for Mencap.” We found the values had lost their meaning locally and local leaders were not using these to lead the culture of the service to enable the delivery of a truly person-centred supported living service. A staff member told us, “They care there is someone allocated to the shift, not who is allocated or if I’m OK, as long as they don’t have to do it.” Another staff member told us, “Communication was often inconsistent, and some emails and concerns were left unanswered. This made it difficult at times to feel confident in the leadership structure.”

The provider had an established organisational structure and there were numerous support functions to support local leaders. However, we found there had not been sufficient face to face visits, initial assessments, or on-going support from these teams.

Leaders were caring and wanted to provide people’s care in a person-centred way. However, we found this did not translate into a consistent vision to deliver a person-centred supported living service and the delivery of this service was not aligned to the provider’s values. This meant leaders had not embedded a person-centred culture in the service.

We raised our concerns with the provider during our assessment who told us they were committed to making improvements at the service to address the concerns that we had identified and made resources available to deliver improvements.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

There was a manager registered with CQC at the time of our assessment and although staff told us they were accessible by email or WhatsApp, the consistent feedback we received demonstrated the registered manager had not been visible in the homes they were responsible for leading. A staff member told us, “The [registered] manager hasn’t been visible at all.”

Staff told us they did not feel supported by local leaders. A staff member told us, “I think we are under supported here.” We found that visits by service managers had not been supportive and were ineffective. There was a disconnect between support local leaders told us they were delivering and how this was being perceived by their teams. A staff member told us, “Face to face visits would go a long way to improve staff morale.” Another staff member told us, “It would be fair to say that until recently, I did not always feel supported at the local level”. We were also told by a staff member, “Service managers are not always visible” and that, “Visits are often on the doorstep, they say they can’t come in because it’s supported living.”

Some staff told us they did not know who senior leaders responsible for the service were and they didn’t visit the homes. A staff member told us, “The [registered] manager never comes here [supported living service], and I couldn’t tell you who the regional manager is.” Another staff member who shared feedback during our assessment told us, “We never see anyone from Mencap.” In response to staff being asked what they would change, one staff member told us, “Stronger manager presence, even if just checking in.” A staff member told us towards the end of the assessment the area and regional manager had just visited the service; however, they felt it was a shame this had been prompted by the CQC assessment. The provider confirmed that the Regional Operations Manager had visited services on three occasions in 2024 and once in 2025. Visits were also completed in 2025 by the Chief Executive Officer and the Executive Director of Personal Support England. Service managers and support staff had also been invited to roadshows with the senior management team.

Feedback from relatives about the management was mixed. Relatives told us, “The management changes regularly,” “Management are very poor,” “I think the managers are good but there have been lots of changes and I cannot remember their names,” “Management has changed frequently,” and "I have not met the new one yet.”

The oversight of the service was not adequate. This meant that we were not assured the provider had adequate oversight of the systems and processes to drive the improvements needed. We raised our concerns with the provider during our assessment who told us they would make improvements to the local leadership approach. The provider also told us senior leaders, including the Chief Executive and Executive Director of Personal Support were visiting the homes to support the delivery of improvements.An accountability process was already in place for the management team and the Regional Operations Manager met with the Registered Manager every month. However, since the assessment, the provider has increased the frequency of these meetings to help oversee the improvements required."

People did not always feel they could speak up and that their voice would be heard.

The provider had a whistleblowing policy and all of the staff we spoke with during our assessment were able to describe how to raise an internal concern following the provider’s process. We observed evidence in most staff sleep rooms in the supported living homes of the contact details to speak up. However, staff were not assured that action would be taken to address concerns. For example, a staff member told us, “I don’t feel staff speak up enough as nothing is done.” Another member of staff told us, "I don't feel I am listened to by my manager," and "I feel [manager] does not deal with safeguarding concerns well and allegations of abuse have been downplayed."

We were not assured that people always had the opportunities to speak up because managers did not spend adequate time in the services and there was a lack of supervisions.

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.

Managers told us they made reasonable adjustments for staff working in the service. For example, one manager told us adjustments had been made to a member of the teams working pattern as they were unable to carry out sleep-in shifts due to their medical condition.

There was a diverse workforce supporting people who access the service. Staff told us they felt there were limited opportunities to develop their skills and knowledge. For example, staff told us that due to the flat organisational structure there were no opportunities to develop to become a ‘senior support worker’ and the role of ‘service manager’ was too big of a jump.

We discussed this feedback with senior leaders during our assessment and although there were no plans to change the structure, they felt they were able to offer opportunities to support staff development, and the provider had processes in place to support and acknowledge the contribution of staff wishing to develop.

Although the provider assured us there were processes in place to support staff development and acknowledge this contribution, the absence of supervisions, appraisals and evidence of this approach meant further work was needed to embed this in practice.

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.

The provider had systems and processes to assess and monitor the quality and safety of the service; however, the oversight arrangements of these had failed to implement these effectively in the service. This meant the provider had failed to assess, monitor and make improvements to the service and had not identified all the shortfalls we found during our assessment.

The registered manager told us that 6 monthly medicines audits and 6 monthly environmental and operations manager risk assessment audits were carried out at the supported living homes. However, they were not able to evidence these audits had been completed for all supported living homes overseen by this service in 2025.

During our assessment we found the systems and processes in place to assess, monitor and improve the quality and safety of the service in relation to areas such as care planning, health and safety, medicines management, mental capacity, infection control, supervision training, outcomes and restrictive practices had failed. For example, no care planning audits were completed to ensure care plans and risk mitigation plans were effective.

There was some evidence of oversight visits from some local leaders following feedback from CQC prior to the commencement of this assessment. However, these records did not demonstrate effective oversight of the service that focused on quality and safety, nor did those completed identify the concerns found during this assessment.

The registered manager shared the business continuity plans for the service and told us these had recently been distributed to all of the homes. However, staff were not able to locate the plans at two of the supported living homes we visited. This meant staff did not have access to guidance for responding to an emergency situation.

Our assessment found widespread and significant shortfalls across the supported living homes under this registration. We identified regulatory breaches relating to safe care and treatment, staffing and good governance. This meant service users have been placed at risk of not receiving planned care and have been exposed to the risk of unnecessary harm due to poor governance.

We raised our concerns with the provider during our assessment who took action to strengthen the local governance arrangements. For example, a quality monitoring audit was shared with us that the provider planned to introduce to improve the governance of the service. The provider also told us they had made further resources available locally to support the service to drive improvements.

The provider did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share always information and learning with partners or collaborate for improvement.

A health professional told us the service had, “built a respected relationship with the Community Team for People with a Learning Disability (CTPLD)” and the service, “followed their recommendations” in relation to people’s health interventions.

The provider’s lack of oversight and monitoring of the service impacted the effectiveness of collaborative working and sharing of information. For example, care plans and risk mitigation plans were not always up to date, and did not always detail professional guidance, therefore, we could not be assured that partnership working was supporting effective care.

The local authority had increased monitoring of the care provided by the service as they were not assured by the provider’s response to identified concerns.

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 had systems and processes in place to analyse and learn from governance practices such as incidents and audits. However, the local implementation of these did not support learning and improvement. The registered manager told us there was no service improvement plan in place and we found quality assurance processes were not providing adequate oversight for leaders to ensure continuous improvement and sustainability. For example, a medicines audit completed in January 2025 had failed to identify expired medicines at a home that we discovered were still in the person stock 6 months later.

During the assessment the registered manager shared an audit completed by the provider’s quality assurance team, however, not all homes had been audited, and we were concerned by the number of recommendations, absence of a risk rating and deadlines for the recommendations, and the practical delivery of the improvements. We raised our concerns with the provider who arranged for the themes from these audits to be group together to support improvement across all homes supported by this service.

The provider’s oversight of systems and processes to support learning, improvement and innovation had failed to identify and deliver sustainable improvements. Where learning had been identified, this had not been used to make improvements across the whole service in a timely manner.

We met with the provider during our assessment to share the concerns we had identified. The provider was receptive to the feedback we shared and sent us an action plan to outline the steps they were taking to improve the oversight of the service and address the shortfalls we had identified. The provider committed to sharing regular updates to demonstrate the improvements being made and told us they were using our findings to reflect how they had not met the standard they expect of their services. The provider also told us they would be using this reflection and learning, to feed into their various committees to consider what changes needed to be made as a result.

Although the provider shared assurances that action was being taken in relation to the findings during our assessment, further work was required to be assured that these actions lead to sustained change and improvement across the service.