DDLTAC(UK) - LONDON

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• 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.

The service was in breach of legal regulation in relation to good governance.

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 provider 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.

The provider told us staff were given a staff handbook which included the provider’s mission statement, values, expectations and code of conduct. However, not all staff had received the handbook or the provider’s mission statement, values, expectations and code of conduct.

A member of staff told us, “I have not received a staff handbook, values, code of conduct.” Another staff member said, “The registered manager said she would email it [staff handbook] to me but I have not received it.”

Leaders did not always have the skills, knowledge and credibility to lead effectively.

The provider was compassionate and inclusive. However, leaders did not always demonstrate the required level of skill, knowledge, and credibility to lead effectively. The registered manager, who was also the nominated individual and the provider, did not always have sufficient knowledge of legislation and its requirements and did not always operate governance systems and processes effectively. They were unaware of the AIS, unaware learning disability and autism training has been compulsory for all staff since 2022, did not carry out DBS checks for staff as regularly as required and did not always operate quality assurance systems and processes effectively to ensure learning to improve the service, for example.

We have addressed this in more detail in the governance, management and sustainability section below.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The person and staff told us they felt comfortable to ask questions, raise concerns and discuss issues and ideas with the provider and believed they would take action to address their feedback.

A member of staff told us, “If something happens, I am comfortable to speak with the registered manager. Another staff member told us, “I feel comfortable to raise issues. I am confident the registered manager will take action.”

The registered manager said, “They [staff] do feel comfortable to raise concerns, they ring me at any time or come in to see me.”

The provider did not always proactively work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Not all staff, including the registered manager, had completed Equality, Diversity and Human Rights (EDHR) training. In addition, the provider’s training record stated EDHR training was not applicable to the registered manager (who was also the Nominated Individual and the provider.) There was no evidence the provider had a plan or a system and process in place to ensure an inclusive and fair culture by improving equality and equity for people who worked for them.

However, the provider valued diversity in their workforce and staff were happy working there. One member of staff told us, “I feel supported, any difficulties or changes I want to make I speak with the registered manager, and she manages the situation and I am satisfied. I think they [the provider] will provide a secure environment and career.” Another staff member said, “It is good working here, I am happy here.”

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 did not operate their quality assurance systems and processes effectively. Their reviews, audits and oversight had not identified the issues we found during our assessment of the service.

There was confusion regarding who was the designated safeguarding lead (DSL) for the service and what duties the role included.

The provider had not ensured all the person’s care records were accurate, complete and contemporaneous, including their needs assessment, risk assessments and care plan. The provider’s safeguarding, whistleblowing and supervision polices required updating.

The provider’s care call monitoring data was not robust, as most of it was logged manually, even though staff knew how to use the electronic system and had logged a number of care calls using the electronic system. This meant the care call monitoring data could not be relied on for accuracy, which made it less likely the data could be used to learn lessons to improve the service.

The provider’s Business Continuity Plan did not include sufficient information about staff roles and duties, key contacts, the emergency contact details for utilities and the contingency plans for staff shortages, a fire in the office or data breaches. This meant it was not robust and the provider could not guarantee continuity of service in the event of an emergency that threatened the operation of the service.

These issues put the person at risk of potential harm.

This was further evidence of a breach of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 17: Good governance

However, we found no evidence the person had been harmed.

The provider 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 provider worked in partnership with GPs, various other healthcare services, and local authorities. The service was well known by local community organisations.

The provider 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 had not always effectively operated their quality assurance systems and their processes for learning, including audits and accident and incident reports, for example.

However, they were linked in with information and practice networks to support learning and improvement. The provider was linked in with Skills for Care and the registered manager participated in a local authority support network for registered managers and providers. The provider received information online from NICE and received updates from CQC. The provided had also attended training provided by CQC. Skills for Care is the strategic workforce development body for adult social care in England. They collaborate with the government and care employers to ensure the sector has the skilled staff needed to deliver high-quality support.