Baobab Care UK 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 inadequate systems, processes and 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 equity, equality and human rights, diversity and inclusion, and engagement. They did not always recognise and address the challenges and the needs of people and their communities.

The provider failed to take consistent and timely action in response to risks and concerns. They did not prioritise safe and high-quality care or the promotion of a culture focused on learning and improvement.

Staff meetings, supervisions and spot checks had not been completed for all staff to effectively identify where additional staff support was required. Some staff we spoke with, did not have the ability to tell us about their learning from training which demonstrated a lack of knowledge and understanding. This meant we could not be assured the current training met the needs of all staff.

Procedures in place for developing and reviewing people’s care plans did not demonstrate a fully inclusive and collaborative process.

The provider’s training for staff did not reflect people’s individual needs or fully promote equality and diversity. We found risk assessment and care planning processes did not fully reflect or acknowledge people’s individual needs or risks and required further development.

Environmental risks including IPC had not been suitably assessed to ensure people lived in clean and safe environments.

Medicines and finance management lacked robust and safe procedures to ensure these were stored and managed safely.

The registered manager told us they supported an open culture which staff confirmed in their feedback to us. Staff had not received training in recognising closed cultures, but they could tell us what they would do if they witnessed poor practice by the registered manager and how they would escalate this. They said they were confident if they reported concerns, that it would be acted on by management. However, they did not recognise the poor practices we found during our assessment. People and relatives told us staff were kind and compassionate.

The provider did support leaders at all levels to fully understand the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not demonstrate they had the skills, knowledge, experience to lead effectively.

During our assessment the registered manager and provider engaged with us during the onsite visit, feedback on our findings and responded to our requests for information. However, due to a lack of organisation and poor systems and processes in place some information had to be requested up to 3 times. The provider was receptive to our feedback and took some steps to immediately improve shortfalls which we identified during the assessment. They told us that this assessment had been a big wakeup call and made them realise they had relied on their team to carry out their duties with them having little or no oversight of what was being reported back to them. The provider and registered manager failed to carryout audits or checks of the reports senior team members were sending to them. This meant they could not be assured what they were told had been completed and this was evident during the assessment.

Actions identified from audits completed by senior staff were not added to any action plan. We found the provider could not evidence that some required actions in relation to improvements had been completed in a timely way or even at all.

Where audits had been completed for medicines management and incidents and accidents, we found these to be ineffective in identifying required actions or ensuring actions were completed. This meant shortfalls and priorities for the quality and safety of people’s care had not been improved. We found where the registered manager had delegated tasks to other staff, they failed to demonstrate that team members had the appropriate skills, knowledge and support to carry these out effectively. For example, these staff who had additional duties had no recorded evidence they had been trained or supervised in carrying out these tasks.

Supervisions which had been completed included discussions with staff around training to carry out their roles and provided the opportunity for staff to identify additional support or development needs they may have. However, the registered manager could not demonstrate they had carried out such supervisions with all staff, in line with their own policy. They could not demonstrate where actions had been identified that these had been completed and revisited via supervisions. This meant we could not be assured the supervision system was effective in driving improvements in staff knowledge and skills to fulfil their roles effectively and safely.

People and their relatives told us they knew who the registered manager was. Whilst some spoke positively overall about them telling us they were approachable others felt they did not take actions when raised with them about their loved one’s support needs.

Staff told us they felt supported by the registered manager and understood their roles and responsibilities.

People did not always feel listened to when they spoke up, leading to them feeling unheard at times.

The provider’s approach in gathering feedback from people to give them the opportunity to share any concerns they may have was not fully effective. Some people or their relatives told us they had not been asked for their feedback.

The staff training records did not demonstrate staff had received whistleblowing training, as per the providers policy and not all could tell us what whistleblowing meant. This meant we could not be assured staff were aware of the process to follow if they spoke up and that their voice would be heard.

Staff told us they could raise concerns with the registered manager or provider at any time and felt they would be listened to and actions taken.

The provider did not always demonstrate they cared about and promoted the wellbeing of their staff or support and enable staff to always deliver person-centred care.

The provider engaged with staff in gathering information to identify any staff members with protected characteristics such as communication needs and religious needs. This meant the provider could demonstrate they worked with staff members to promote and support equality in the workplace.

Although records demonstrated staff had received some training, we found this was not adequate to ensure staff had the appropriate skills to safely fulfil their roles and meet people’s known support requirements and needs safely.

We saw from records provided that just 29 of the 83 staff had received equality and diversity training to improve their awareness of these principles. In addition, the provider had failed to implement a robust process to assess staff knowledge and skills and how they applied this in the service. The registered manager told us if staff required additional support with learning, they would facilitate this. However, we found some shortfalls in staff members’ ability to describe their learning and understanding of certain key topics. Training was mainly delivered via an on-line training platform. The providers operations manager told us that they had recently introduced that staff attend the office to complete their training so they could have oversight of who was completing the training and be on hand if staff needed to discuss anything in relation to the training completed. Our findings demonstrated further improvements were required to staff training to demonstrate they were effective.

Staff told us they were happy working for the provider.

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 implement effective processes and systems to monitor the quality of care provided and drive improvements. Audits which had been completed had not identified the concerns we found in the service; therefore, we were not assured these were effective. For example, we found inaccurate and unclear information in some people's care and risk management plans. There was poor guidance for staff and a lack of effective monitoring. Process to monitor the quality of medicines management was ineffectiveness this meant opportunities to drive improvement in the service to benefit people and ensure their safety had been missed.

We saw the provider had failed to fully assess environmental risks and implement suitable assessments or escalate these to the landlords of the properties on behalf of people.

Policies and procedures were not consistently implemented in the service or accessible to staff. We found in many areas the provider failed to adhere to their own policies. This meant their actions were not always fully reflective of current legislation.

The provider did not complete comprehensive staff recruitment checks which was unsafe. This included a failure to consistently request DBS checks, explore gaps in employment or obtain suitable references.

The effectiveness of staff training was not assessed or monitored, and there was a lack of checks to demonstrate staff were competent to carry out their roles. The lack of oversight by the provider meant they could not assure themselves that staff were skilled and had the necessary knowledge to undertake their job roles safely.

We found support plans and risk assessments did not contain adequate information and were not formally or effectively audited, which we found during our assessment. This meant people were placed at risk as the provider's systems failed to provide staff members with robust information to keep people safe.

Whilst we recognise the provider was receptive and responsive to our findings during this assessment, the systems in place should have been comprehensive enough to identify the shortfalls in the service and enable them to make the necessary improvements.

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.

The involvement of healthcare professionals such as district nurses or equipment providers was not always clearly recorded in people’s care records. Neither was it clear how the provider engaged with others, so people could remain safe and independent. This was especially concerning for vulnerable people who were a known high risk of leaving their homes for long periods of time.

Staff told us they could make referrals to health and social care professionals via the management team or where appropriate to support people to do so independently. Relatives we spoke with, and the provider confirmed, relevant health and social care professionals were involved with people’s care. However, we found 1 occasion where a referral to health professionals had been delayed as the registered manager had not taken timely action. One relative told us although they had POA for health and welfare, they were often not consulted in relation to appointments or decisions around their loved one’s health needs.

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 lack of effective systems and processes to monitor the safety and delivery of services evidenced there was no appropriate systems in place for the provider to identify shortfalls and take lessons learnt from findings.

There were shortfalls in the quality and safety of people’s care which were identified at this assessment. Our assessment identified breaches of good governance, person centred care, safeguarding people from abuse, safe care, staffing and fit and proper persons employed.