Evolving Care Ltd Leicester

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.

This service scored 61 (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 vision and values in place; however, these were not always consistently embedded across the workforce.

Staff demonstrated an understanding of the service’s vision and values. However, these were not consistently embedded within the staff culture or experience. Feedback from staff was mixed, with some reporting they felt well supported and positive about their role, while others did not feel consistently valued or listened to. These concerns were shared with the registered manager at the end of the inspection to support improvement in staff engagement.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. However, oversight arrangements were not always effective in identifying concerns relating to medicines management, risk documentation and record keeping. This meant opportunities to address some issues proactively had been missed. Despite these findings, staff and relatives also gave examples of the management team responding to changes in people's needs and working to ensure appropriate support was in place.

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

Although staff understood how to raise concerns and were aware of external reporting routes, some staff told us concerns they had previously raised regarding rota management and working arrangements had not resulted in action or change. This reduced their confidence that raising concerns internally would lead to a positive outcome. Staff were able to describe a range of routes available for escalating concerns, including the office team, the local authority and CQC. This meant processes to support speaking up were in place, but staff confidence in their effectiveness was not consistently assured.

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.

Most staff told us they had been treated fairly and described how the provider had considered their individual circumstances, including caring responsibilities, and accommodated working arrangements where possible. However, some staff felt their individual circumstances had not always been considered in the same way. This meant staff did not always experience support and flexibility consistently across the workforce. The registered manager acknowledged the mixed feedback and provided assurance that staff engagement and support arrangements would be reviewed to promote a more consistent staff experience.

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

Governance systems were in place to monitor the quality and safety of the service; however, these were not always fully effective in identifying all areas requiring improvement. During the inspection, we found records did not consistently demonstrate that PEG flushes and tube rotation checks had been completed in line with people's care plans. Staff demonstrated a good understanding of the care required and were able to explain how PEG-related risks were monitored and managed, providing assurance that care was being delivered in line with people's assessed needs.

While the provider completed audits and quality assurance checks, some of the issues identified during the inspection, including aspects of medicines management, risk documentation and care recording, had not been identified through these processes. This meant there were opportunities to further strengthen oversight and ensure records consistently evidenced the care and support being delivered.

The registered manager demonstrated an understanding of the areas identified and responded positively to feedback. They provided assurances that actions would be taken to improve record keeping, strengthen audit processes and support ongoing service improvement.

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.

People and their relatives told us the service worked well with health professionals to support safe and effective care. Staff explained they made referrals through the office team and that any advice or guidance received from health professionals was shared promptly so people’s needs could be reviewed and responded to. The registered manager told us some people and their relatives chose to access their care records online.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The registered manager welcomed our feedback and demonstrated a clear understanding of the areas identified during the inspection. They were responsive throughout the inspection process and had already begun taking action to address concerns and drive improvements. This included reviewing relevant documentation and implementing changes to strengthen oversight, record keeping and quality assurance processes. Their proactive approach provided assurance that the issues identified were being addressed and that there was a commitment to continuous improvement.