Naidcare

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.

During our assessment of this key question, we identified a breach of the legal regulation in relation to good governance. This was because we found concerns around the effectiveness of the provider's quality assurance and oversight systems and processes.
 

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Although the provider recognised improvements were needed, governance and leadership arrangements were not sufficiently robust. This meant that day-to-day monitoring and assessment were not as effective as they should have been, creating a risk that the service might not always be safe or consistently meet people’s needs.

The provider did not always understand the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. There was a clear staffing structure in place with a field supervisor managing the day to day running of the service; however, there was no registered manager in post. The provider acknowledged changes were required to make improvements to their service. They told us they were actively recruiting for a registered manager.

The service had policy and processes for staff to follow on ‘whistle blowing’. The field supervisor had developed a listening culture where staff felt they were available for them to talk to. This meant staff felt supported, valued and confident to raise concerns or seek guidance, which contributed to a positive working environment.
People and relatives told us they were given the opportunity to provide regular feedback. A person told us, “I have had several feedback questionnaires over the years I have been with the service.” However, the results were not analysed for any themes or trends to see where improvements could be made. Staff told us they had supervisions. A staff member told us, “The supervisor carries out supervision.” However, we found limited evidence supervisions and spot checks were being carried out regularly.
 

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. There was a policy in place to protect staff from harassment and bullying and a focus on protected characteristics under the Equality Act. The provider had developed an inclusive workforce and recognised the value of diversity amongst the team.

The quality assurance and governance arrangements in place were not always effective in identifying shortfalls at the service. Audits were not completed regularly, lacked detail and were mostly a tick box exercise and did not identify the shortfalls we found. This meant effective auditing arrangements were not in place to assess, monitor and improve the quality and safety of the service provided. Staff meeting minutes did not include action plans completed to evidence how issues raised were to be addressed, dates to be achieved and if actions had been resolved or remained outstanding. There was a lack of monitoring by the provider in the absence of a registered manager, who did not demonstrate appropriate management oversight of the service.

The service 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. The field supervisor and provider had developed good links and worked closely with health professionals. They were working with the local authority and an external auditor to aid improvements at the service. The field supervisor had developed good relationships with the local GP, district nurses and mental health professionals. Staff were aware of the importance of working alongside other agencies to meet people's needs and liaised with other healthcare professionals such as the GP and pharmacy when required.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.
The provider understood improvements were needed. They encouraged staff to discuss and share ideas for improvement and innovation. The provider was passionate about making improvements in the service and told us, “I understand there is room for improvement, and I will be working hard to make those changes.”
The organisation was clear about their vision and values and were aware they had more work to do to ensure all processes were communicated clearly and embedded to support learning and innovation.