Eureka Care Services 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 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 governance at the service.

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.

The provider is the registered manager, and we found no evidence to show how their culture was reviewed, assessed and monitored through external scrutiny. We found several indicators that the service operated as a ‘Closed culture.’ This is a culture whereby a lack of transparency and effective leadership can allow cultures to develop that can cause harm to people using services. Staff spoken with were unable to describe to us the vision or culture of the service. Staff used varying words, such as ‘Caring,’ ‘Treated equal,’ or ‘Supportive.’ However, no staff member could tell us about the core values and culture of the service. Staff were unaware that the local authority had taken action to place an embargo on referrals due to their own recent assessment findings. This did not demonstrate a culture based on transparency, equity, inclusion, and engagement.

We identified during this assessment poor training and supervision of staff providing care. Staff were not supported to reflect on practise or receive training relevant to their role. There had been a high turnover of staff with consistent staff shortages. These areas were not identified by the provider as impacting on people’s care and leaving them exposed to harm.

There was no evidence of regular or effective engagement with staff to ensure they understood or upheld the service’s purpose and values. The provider was unable to monitor staff practice against their values as these were unclear.

Leaders did not demonstrate sufficient understanding of their regulatory responsibilities, including the statutory notifications they were required to submit to CQC. This lack of regulatory awareness contributed to weak leadership oversight and reduced assurance that the service was operating in line with legal and regulatory requirements.

The registered manager did not always understand how to manage and provide care and support. We have highlighted in this report where we identified that the registered manager lacked oversight of key areas including risk assessments, mental capacity and governance. They were not fully aware of national frameworks such as Right Support, Right Care, Right Culture, which limited assurance that these principles were consistently embedded for people with autism or learning disabilities. While the provider was caring and committed, these gaps meant leadership capability required strengthening.

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

Staff told us they felt confident in raising concerns with the provider and they felt safe in doing so. One staff member said, “We can speak out if we are worried or not happy. I can speak out in a meeting or just in the office alone. I don’t feel the need to now, but I know I can if I think something is wrong and it will be dealt with.”

However, staff had few meaningful opportunities to share ideas or offer feedback. The provider did not hold regular team meetings that were meaningful and gave staff that opportunity to raise concerns or ideas. Supervision was observations of care and not formal meetings to enable staff to discuss concerns, improvements or ideas.

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.

Systems or schemes were not consistently in place to promote staff wellbeing. Staff had raised no concerns about how they were treated, however the service had undergone significant changes with staff leaving over the past 12 months. The provider had not looked at the reasons for staff leaving to review their workforce culture and how to review their approach to equality and diversity.

The provider showed us examples of staff supervision however, when we looked at these records we saw each month was a duplicate of the previous month’s supervision. These did not demonstrate an approach by the provider that embraced an inclusive and fair environment for all staff.

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

This assessment found widespread shortfalls across the service. We identified breaches relating to safe care and treatment, safeguarding, staffing, consent, and good governance. These failures placed people at risk of not receiving high quality planned care and exposed them to risk of avoidable harm through a lack of leadership and oversight.

There were significant governance failings relating to the management of the provider's sponsorship licence and leadership roles. The provider’s sponsor license had recently been revoked. They were able to employ staff sponsored by other care agencies but only on restricted hours. We found examples where the process to ensure staff were working legally continued to not be followed.

Quality assurance systems were inadequate. There were shortfalls in incident and accident reporting and management. Where incidents were reported, these were not responded to correctly, reviewed or followed up which then had not been identified through any provider audits.

Systems did not identify where assessments were not in place for people or reviews had not occurred when required. Incidents were not reviewed when needed and did not inform the provider of trends to act proactively to reduce risks. Training for the provider and staff did not meet the levels required, and for some staff, training had not been completed. Systems in place were not used to identify where these improvements were needed.

Mental capacity assessments had been completed for all people, including those without capacity concerns, indicating a blanket approach. This further supported the evidence seen to demonstrate Eureka Care Services Limited operated as a closed culture.

The local authority had visited the service recently which identified a number of the concerns found by CQC months after this visit had concluded. The provider had not developed a robust improvement plan to address those concerns, therefore when we inspected we found many of those improvements were ongoing. When we asked the provider why actions had not been undertaken, they replied, “Concerning my governance and audits, I am out there and always if anything is happening, I am around to get it sorted and minimise the risk. The only thing I need to improve on which I have made improvements on is my documentation. If I am in the field, it is difficult to put things down on paper. I have seen the importance of finding time to do this.”

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.

We were told by people and relatives about examples where staff worked in partnership with GPs, social workers and health professionals. However, the wider governance issues and lack of a collaborative approach to reviewing people’s needs meant the impact was felt by people as their care was not joined up, resulting in gaps and delays in care.

Feedback from local partner agencies demonstrated concerns regarding the integrity and overall competency of the management and raised questions about the reliability of governance processes that underpin effective partnership working.

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 did not have effective oversight of how care was delivered and monitored. This meant opportunities to analyse and review accidents and incidents for themes and trends were missed. Learning was therefore not identified or shared with staff. Meetings did not reflect or discuss innovation or improvement that would contribute to a better outcome for people and staff. One staff member said, “We talk about clients’ needs, punctuality, the role we play. I am not aware of the local authority inspection and not asked about service improvements. We don’t get any feedback about incidents really, we report things to [Provider] and that’s the end of it. I don’t know what happens after.”

The provider did not engage with local organisations to share practise or seek ideas for innovation within their service. Their main support with learning was through a training provider who did not support them to reflect on their practice and embed appropriate development for staff. The service was registered as a service to provide personal care to people with a learning disability and / or autism. There were no policies or best practise to share among staff to ensure continuous learning was embedded to ensure people’s freedoms and choices were constantly reflected on to drive improvement.

This meant improvements to the service and the care people received were not always considered or put into place.