Archived: My Life Choice

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 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 provider was in breach of the legal regulations relating to good governance.

This service scored 29 (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 placed people at the centre of their support when decisions about their lives were being made. People and those important to them did not feel the provider engaged positively with them to discuss how to improve the care people received.

The provider had failed to promptly identify and address concerns within the culture of the service. The provider had not ensured people’s relatives and relevant health professionals were involved in discussions about increased incidents and concerns. People did not always feel listened to and there was a lack of senior management oversight of each person’s care. This increased the risk of closed cultures developing.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care and support. Leaders did not always demonstrate they had the skills, knowledge, experience and credibility to lead effectively. Leaders did not always use appropriate language when describing people’s care needs. This meant they were not consistently role modelling positive, respectful behaviours and values within the service.

At the time of the inspection, the registered manager was no longer in the service and there had been several changes in management structure and accountability. Leaders were not able to demonstrate a robust understanding of the extent of the concerns at the service. Whilst the management team had identified some of the issues we found at the inspection, they were not able to demonstrate how they had prioritised the most significant concerns to ensure immediate actions were taken to ensure people remained safe.

People did not feel they could speak up and that their voice would be heard. The provider had policies in place to provide guidance on whistleblowing, speaking up and managing complaints. However, we found the provider had not always responded appropriately to concerns being raised. The provider had not embedded an open culture of reporting and acting on concerns and this meant people were not protected from the risk of harm and abuse.

The provider had policies in place to ensure equity in their recruitment and development opportunities. However, we received mixed feedback about how well the provider listened to the individual experiences and challenges of staff. Staff did not always feel confident their concerns and ideas would result in positive changes to their roles or to the service.

The provider’s governance processes were not effective. The provider had failed to robustly assess, monitor and improve the quality and safety of the service.

The provider was not able to demonstrate how their governance processes protected people from the risk of harm and abuse. The systems in place to identify and manage incidents and safeguarding concerns were not safe and did not demonstrate management oversight of risk.

Leaders did not have clear systems of escalation and accountability. For example, where concerns were identified with people’s care and support, it was not clear that information had been reviewed and acted upon by all levels of management to ensure concerns were promptly shared with relevant authorities. Notifications were not consistently submitted to external organisations as required.

At the time of the inspection, we identified immediate concerns with the oversight of risk and people’s safety and with staff competency and training. We also identified significant concerns with the providers processes for assessing people’s capacity to consent and a lack of person-centred, dignified care. The provider’s model of care did not follow best practice guidance and leaders did not demonstrate a commitment to reducing the restrictions in people’s lives. The provider’s governance processes had failed to identify the extent of these concerns or evidence prompt action to address them.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. The provider had not ensured health professionals were notified of all relevant changes and concerns relating to people’s care to ensure prompt input and action to meet people’s needs.

The provider did not work collaboratively with people, those important to them or staff to develop an approach which focused on delivering person centred care and supporting people to achieve good outcomes.

The provider did not focus on continuous learning and improvement.

At the time of the inspection the provider told us they were already taking action to drive improvements in the service and they had commissioned an external quality audit and implemented a service improvement tracker. However, we found the tracker was not accurate, with actions marked as completed in areas where we identified concerns.

The external audit completed in April 2025 had identified required improvements in relation to safeguarding, risk and incident management, positive behavioural support plans, lessons learnt and staff training. However at the time of the inspection, we identified continued serious and immediate concerns in these areas. Leaders demonstrated a poor understanding of how to make effective and prompt improvements happen.

The provider did not encourage innovation or promote creative ways of delivering equality of experience and outcomes for people using the service. The provider was not able to evidence how they continuously reviewed and developed people’s care to explore meaningful opportunities for people to enjoy a full life.