Social Care Solutions Ltd (Herts & Bucks)

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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 inadequate. This meant the management and leadership was inconsistent. Leaders and the culture they created did no support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good 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 service lacked a clear shared vision, strategy and culture which was 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 managers and regional manager acknowledged the need for stronger governance and leadership to improve quality monitoring, safety, and needs-based care. Additionally, the service had not consistently completed regular monitoring, shared learning from incidents and auditing processes and had not established sustainable practices.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. At the time of our assessment there was no registered manager in post. Feedback we received from staff, people and relatives about the managers currently overseeing both supported living settings was positive, however they all raised concerns regarding the lack of any external senior leadership support. Comments included, “With the manager here I do feel supported. The wider organisation not so much,” “Are there plans to recruit another area manager who is able to support with this very difficult task of improving things” and “It is slowly improving, if [managers name] gets support from above, but they are not getting any support. I try to support staff, but there is no support from the organisation or HR.”

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. The provider had failed to provide the necessary support systems to equip managers with the skills to effectively manage both supported living settings day to day in the absence of a registered manager.

Staff did not always feel they could speak up and that their voice would be heard. Leaders did not actively promote staff empowerment to drive improvement. Leaders did not encourage staff to raise concerns and promote the value of doing so. Staff were not confident their voices would be heard when raising concerns to the senior leadership team, investigated sensitively and confidentially and lessons shared and acted on. We received mixed feedback from staff about their experiences of speaking up. Comments included, “It is easy to report to the manager but not sure what happens after. I do not think they (senior leadership team) always listen 100%, I think if more than 1 staff member speaks out, they may listen,” and “It really stops with [Name of manager], I am confident they escalate concerns, but we are not always confident they (head office) listen to us.”

The provider valued diversity in their workforce. However, they did not always work towards an inclusive and fair culture by improving equality and equity for all people who worked for them.

The provider employed a diverse workforce from varying backgrounds and cultures. However, not all staff felt they were treated equally, and protected characteristics were not always effectively supported by management.

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, or share this securely with others when appropriate. The provider failed to demonstrate their governance systems and processes to assess, monitor and improve the quality and safety of the service were effective and evidenced robust oversight of both supported living settings. Auditing processes had either not been completed or regularly completed. Audits which had been undertaken had not identified concerns / issues we found on the site visits of our assessment.

We reviewed the 4 weekly medicines audits provided by the regional director for December 2024 and February 2025. Neither of these audits identified a medicine was being administered to a person 8 months past its expiry date. Both audits had a 100% compliance score. No further audits had been undertaken until the regional director undertook an audit on the 26 May 2025. This audit achieved a compliance score of 14% and identified an ongoing medicine error from February 2025 which the regional director then notified the Integrated Care Board and CQC.

Audits of people’s daily logs had not been undertaken or reviewed since the absenceof the manager, there was no effective monitoring of people’s records and a failure to follow up on concerns we identified in 1 person’s daily notes.The provider failed to ensure in their arrangements for assessing and checking the quality and safety of peoples care who use the service. The systems in place had failed to maintainaccurate, complete and contemporaneous records for some people using the service as not all risks to service users' safety and wellbeing were being recorded or accurately reflected their needs.

The provider had not always understood 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. However, the manager at 1 of the supported living settings with the support of the senior leadership team had been working closely with local authorities, attending strategy meetings and working through a plan of identified actions to improve outcomes for people. We received positive feedback from a visiting professional to this supported living setting who told us, “The manager has always been responsive via email and welcomed our input. There were some initial issues with staff not being aware of my guidelines leading to confusion and lack of compliance. The manager responded to this; reported that they had raised a safeguarding and was proactive in arranging a training session with my team.”

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. However, improvements were being undertaken within the service, with a focus on improving the environment, upgrading software systems and investment in staff training and recruitment which was ongoing.