Callquest For Care

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.

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

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion and engagement.

The provider had a shared and person-centred culture that was valued by people and staff. Staff described a positive and supportive working relationship with the registered. They said, “We work well… the manager is lovely really lovely.” The staff member went on to say, “I am proud of the company as they respect me, and I respect them and the clients.”

People and relatives said they were happy with the consistency of care and being able to contact the registered manager easily.

Systems to fully embed a clear vision and values across the service were not consistently developed. Records such as surveys and quality assurance processes appeared to have been introduced shortly before the inspection and were not yet embedded in practice. Despite this, the small size of the service enabled close working relationships that supported a positive culture and responsive care delivery.

Leaders did not always demonstrate the skills and systems needed to lead the service effectively. While the registered manager was described positively by staff and people, there were gaps in their oversight and knowledge of regulatory requirements. For example, the registered manager told us they “did not know” they needed to complete certain risk assessments and acknowledged care records required significant improvement.

Training and development were not well established. The registered manager confirmed, “We do not have [a training programme]” and staff told us they had not completed essential training such as safeguarding or moving and handling. This meant leaders could not be assured staff had the skills to provide safe care.

Improvements were needed to ensure the registered manager had the capability and systems to lead effectively but they were compassionate and approachable. Staff said the registered manager regularly checked on their wellbeing and provided practical support.

The registered manager showed a responsive approach and used the inspection as a learning opportunity. They took action following the assessment to create a plan to address shortfalls in practice.

The provider did not always have effective systems to ensure people and staff could consistently share feedback and concerns. While staff said they could raise issues and had “no concerns,” there was limited evidence of structured opportunities for speaking up. The staff survey also highlighted gaps in awareness, with low confidence in reporting channels and safeguarding knowledge. This meant the provider could not be assured staff fully understood how to escalate concerns safely. Staff described informal opportunities to speak with the registered manager regularly due to the small size of the service, and meeting notes showed that staff were asked if they had questions or ideas.

Feedback systems were not fully embedded. A relative and a person both told us they had not routinely been asked for feedback, and the registered manager was introducing surveys for people and relatives at the time of our assessment.

Overall, although there was an open culture in day-to-day interactions, formal systems to support speaking up required improvement.

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.

The provider promoted an inclusive and supportive working environment. Staff told us they felt valued and respected. The registered manager supported staff wellbeing in practical ways, such as helping them attend appointments. The staff working at the service did not require any reasonable adjustments to support them to carry out their roles at the time of the assessment.

Formal systems to promote equality and inclusion, such as structured training, were not in place. However, the day-to-day culture within the service supported positive relationships and inclusive practice.

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.

Systems to monitor and improve the quality of the service were not consistently effective. The provider did not have robust oversight of risks or care delivery. For example, risk assessments and care plans lacked detail and some risk assessments were missing. The registered manager told us they reviewed these monthly, however there was no record of what the review entailed, and no changes noted on people’s care records in some cases since 2023.

Auditing processes were limited or newly introduced. The registered stated, “I have only now decided to go through the papers to do audits.” Where audits existed, such as medicines audits, these had been undertaken shortly after the assessment was announced, indicating they were not part of routine governance. The audit had not identified the concerns we found during the inspection in relation to medicine practices and recording.

There was also a lack of effective monitoring of care provision. For example, there was no reliable system to ensure calls were delivered for the correct duration, and recorded times did not always reflect people’s experiences. With records of people’s call times reflecting planned time and duration rather than the actual times delivered, this meant the provider could not be assured people received their care as planned.

The registered manager responded to identified concerns during the assessment. Following feedback, they took action to improve medicines management, care records and began arranging training and introducing monitoring systems.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The provider worked in partnership with families and external professionals to support people’s care. Staff described contacting district nurses, GPs and other professionals when needed, and relatives confirmed the registered manager communicated concerns appropriately.

The registered manager told us there had not been any incidents or allegations of abuse that required notifying to CQC or the local authority safeguarding team.

The registered manager told us they offered support to people to access the community but that at this time people they supported did not need this support.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe and effective practice.

The registered manager told us they wanted to keep the service small and continue to provide person-centred care with a small staff team. Due to the small size of the service the provider did not have embedded formal systems to support continuous learning and improvement. The informal measures in place to monitor the safety and quality of the service had not been robust or effective to ensure people received safe and effective care. Audits, training, and quality assurance processes were not well established and had largely been introduced in response to the inspection rather than as part of ongoing improvement. However, leaders demonstrated a willingness to improve. The registered manager acted quickly on feedback during the assessment, including booking staff onto training, changing medicines processes, and introducing new systems. While this showed a responsive approach, improvements were not yet embedded or sustained. We will check this at our next assessment.