St Elizabeth's Domiciliary Care Agency

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 inspection we rated this key question requires improvement. At this inspection the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At our last inspection the provider had failed to ensure governance systems were robust to demonstrate the service was well managed. This was a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Improvement had been made at this inspection and the provider was not in breach of regulation 17.

This service scored 75 (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, engagement, and understanding challenges and the needs of people and their communities.

The service had a clear vision and values that were understood and upheld by staff. Leadership was visible, approachable, and committed to continuous improvement. The providers strategy for coming future was shared with staff, people and relatives to ensure they have a culture that is committed to be open.

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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The provider was proud to share the registered manager had received a leadership award. Staff echoed that the registered manager was a good leader and felt supported.

The service was well-managed and had a clear focus on delivering person-centred care. Leaders promoted a positive and inclusive culture where people and staff felt valued and supported.

A relative said, “The management team at are excellent – They have transformed the moral of the staff and successfully implemented the system changes needed to bring the service up to the brilliant level of care received by all the residents – they are worth their weight in gold.”

The provider fostered a positive culture where people and staff felt they could speak up and their voice would be heard.

People, relatives and staff were regularly asked for feedback, which was used to shape service delivery. The provider encouraged people to attend meetings where their voice could be heard and to share their views about how to make change either within the service or to enrich their lives individually.

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 had policies in place to ensure equality, diversity, and inclusion were supported.

Staff felt supported in their roles and where they had to ask for support, or raise concerns about their roles, they felt heard. A staff member said, “The management have been great, I have health issues, they have listened and made sure I can work safely. I am very happy with the way it is now.” Another staff member said, “I feel listened to, I have been supported all the way through and still remains the same.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risks, performance and outcomes, and shared this securely with others when appropriate.

The provider had quality assurance systems in place to monitor care and support ongoing improvement. These systems placed people’s voices at the centre of decision-making, alongside insights gathered from audits. By identifying themes and trends in audit data, the provider was able to maintain strong oversight and take targeted actions that led to meaningful improvements in people’s lives.

The Registered Manager 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. One professional said, “The management team are always happy to engage and offer information to me when requested. The management team have also reached out to me independently to request support.”

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.

The provider had demonstrated a clear commitment to learning, improvement, and innovation. Following previous inspections, where shortfalls in the service were identified, the provider has taken steps to understand what good care looked like and how to develop a service that was sustainable and responsive to people’s needs and preferences. Leaders spoke with pride about the progress made, reflecting on their journey and expressing confidence in the stability and strong foundations that were now in place to support further development.

A relative said, “The progressive improvements to systems, and the training personnel achieved since the CQC improvement notice issued in 2022 is I believe incredible.”