Unisus Group 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 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 17, Good governance. The provider failed to ensure there were effective processes in place to monitor the quality of the service and identify concerns.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager explained that the vision and ethos of the service were discussed during staff’s induction, supervisions and appraisals.

Staff told us management demonstrated a positive culture. A staff member told us, “I think the service is managed in a good way as the office team is structured well, care plans are always up to date or updated when needed. The office staff always do their very best to support staff whether it be over the phone or responding to emails promptly providing clear information or instruction. We have regular spot checks, I believe the training is up to a good standard with extra training always being offered if needed and I would also add very fair when it comes to availability with rosters.”

However, ongoing concerns raised by people and relatives about missed calls, inconsistent staffing, gaps in training, and care not being delivered as assessed indicated that the provider’s intended culture was not embedded in day‑to‑day practice. These issues suggest that leaders had not fully embedded or sustained the values and behaviours required for a consistently safe and high‑quality culture.

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.

Although systems were in place to monitor the quality of care, leaders had not identified or addressed a poor staffing culture that was negatively affecting people’s experiences of care, as described by people during this assessment.

Staff spoke positively about the management team and reported feeling supported in their roles. A staff member told us, “I would say that I particularly proud of my progression within the company. I am also proud of providing high quality care for my clients and to make them happy and be a part of their day” and “The service is managed in the best way it can be management tries their best to help and be supportive and open communication and leads us in the best way they can.”

The provider fostered a positive culture where staff felt they could speak up and their voice would be heard. Comments included, “I feel supported consistently and know that I can reach out and talk to [quality and compliance manager] or [registered manager] at any time” and “We have monthly meetings where we can put forward our suggestions of how things could be improved but also I do feel confident if I needed to have my say or opinion on something that I could either go to the office and speak to someone or send an email and there would always be a reply.”

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 registered manager explained how they supported staff to meet their religious and cultural needs and to address any experiences of discrimination, and how this was promoted within the service. They also described how staff were supported during religious festivals.

The provider did not have systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

Although the provider had systems in place to assess and monitor the quality of the service, including routine audits, these had not identified the concerns found during this assessment. This demonstrated that governance and quality assurance arrangements were not sufficiently effective in identifying, understanding or addressing risks to people’s care.

The provider did not always ensure that staff attending care calls had received appropriate training or had sufficient understanding of people’s individual needs. Consequently, the quality and consistency of care varied, with some people being supported by staff who were not fully prepared to meet their specific requirements.

Although the provider held weekly meetings with the registered manager and office staff, there was no formal provider audits in place to demonstrate effective oversight.

Policies reviewed clearly set out roles and responsibilities, including who was accountable for implementation and oversight.

The provider 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.

The service worked effectively in partnership with other health and social care professionals to meet people’s needs, and feedback received was positive. A professional told us, “The service communicates with us when support is needed, and they do attend meetings when required, requests for support are usually appropriate, and they are willing to work jointly when concerns arise.”

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. They did not always actively contribute to safe, effective practice and research.

The provider had systems in place to record and review accidents and incidents; however, these were not always used effectively to identify themes or drive sustained improvements in care. This meant opportunities to learn lessons and reduce the risk of recurrence were not always fully realised.

People and their relatives described management as responsive at times. However, they said responses were inconsistent. While some issues were addressed initially, families reported that concerns often re‑emerged due to ongoing staff turnover, ineffective communication, and insufficient oversight and support for new carers. One person told us, “Care deteriorated after changes in who managed the rota, this led to increased lateness, missed calls and inconsistency.”

Staff did not always have access to training and learning opportunities to develop their skills and knowledge. People’s experiences indicated that learning was not always translated into consistent practice, particularly where staff were new, inexperienced or unfamiliar with people’s individual needs.