Caremark Hinckley Bosworth Blaby & Leicester

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.

This service scored 54 (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, openness, inclusion, engagement, and understanding challenges and the needs of people and their communities.

The culture of the service was person-centred, open, inclusive and empowering. Leaders, managers and staff had a good understanding of equality, diversity and human rights, and they prioritised safe and compassionate care. Staff mostly described a supportive and welcoming culture at the service and spoke positively about leaders.

The Managing Director had ambition and drive to develop and expand the service for a positive future. The Managing Director was passionate about keeping people central to the core of the business.

The service 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 mostly had the knowledge, experience and credibility to lead effectively. However, leaders had not identified or addressed long standing issues with care visit scheduling which directly impacted people’s experience and service deliver.

Leaders at the service had a diverse range of training, professional backgrounds and skill sets that enabled them to be an effective, responsive and dynamic leadership team. The Managing director had extensive experience working within health and social care and had completed education on the law. The registered manager had a well-established career in early years services before transferring and adapting their skills and knowledge to working within the adult social care sector. The Field Care Supervisor had experience training others and had received additional learning to better their skills as a trainer. Administration and Human Resource responsibilities were completed by competent staff members with previous managerial experience. Rota coordinators had experience delivering care before fulfilling their new roles.

During this assessment we worked closely with the Managing Director and the Registered Manager. We found them to be friendly, open, honest, reflective and competent health and social care practitioners. Feedback from people and staff supported our observations. One staff told us, “[The Managing Director and The Registered Manager] have it under control it terms of what is required and what people need. They keep things under a good balance. It gives us [staff] the confidence to do the job we do.” Another staff member told us, “[The Registered Manager] is approachable. If you have a problem, you can talk to [them]. If you are unhappy, you tell them and they’ll call you in for a meeting.”

The provider mostly fostered a positive culture where staff and people felt they could speak up and their voice would be heard. However, feedback from staff indicated that not all issues had been addressed.

People told us they felt comfortable raising concerns with their support staff and leaders. The provider proactively engaged with people using the service and staff to ensure they had opportunity to raise concerns and share feedback.

The provider’s policy and procedures supported freedom to speak up. Staff understood how to raise concerns with external agencies if required and knew where to find the provider’s whistle blowing policy if they needed further information. However, some staff felt concerns they had raised about their rotas were being ignored. Evidence during this assessment highlighted that issues with staff scheduling remained a concern.

The provider valued diversity in their workforce. They mostly worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. However, we did receive feedback from some staff indicating they didn’t always feel like staff were treated equally.

Leaders ensured there were effective and proactive ways to engage with and involve staff. Most staff felt empowered and confident that their concerns and ideas resulted in positive change to shape the service and create a more equitable and inclusive organisation.

The majority of feedback from staff was positive. For example, one staff member told us, “There are always managers around if I need support. They are always respectful.” However, some staff did raise concern about fair treatment, stating that they felt some of their colleagues were overworked. Staffing rotas indicated that at times some staff were given heavy workloads, with insufficient time between care visits to enable rest periods and limited days away from work.

The provider had clear responsibilities, roles, and systems of accountability. However, governance systems were not always effective at identifying shortfalls and ensuring high standards of service delivery.

Quality assurance processes were not always effective. The providers quality audits identified shortfalls and drove service improvement. However, we found medicine audits were not always completed in line with the providers policy and there were times when completed audits did not identify all shortfalls.

The provider’s governance systems failed to identify long standing issues with care visit scheduling, impacting the timely delivery of people’s care. The provider also did not ensure that accurate call time data was available to enable suitable analysis of the effectiveness of people’s care.

The providers oversight processes were not always effective. Digital spreadsheets were used to effectively monitor particular areas of the service, such as staff records and employment checks. However, some processes were not always used effectively. For example, there was insufficient data within the provider’s training matrix to ensure oversight in this area. Despite this, staff training needs were well managed. We raised this with the provider, and they created improvement actions to update their training matrix to improve 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.

Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies. For example, they were responsive and engaging throughout this assessment process and promptly shared any information and documentation requested.

Staff and leaders engaged with people, communities, and partners to share learning with each other that resulted in continuous improvements to the service. For example, the provider engaged with the Home Eternal Feeding Service to ensure a person’s specialist nutrition pathways were well managed and reviewed to ensure the best possible care.

The provider demonstrated some learning, innovation and improvement across the organisation and local systems. However, this not consistent and opportunities to identify areas for improvement were missed. They encouraged creative ways of delivering equality of experience, and quality of life for people.

The Managing Director and the Registered Manager were open and responsive to feedback throughout this assessment process. They used the assessment experience as opportunity for learning and development to improve the quality of service for people. They demonstrated sincere, thoughtful and professional character throughout the assessment, that enabled a positive learning culture at the service. However, they needed to apply more stringent oversight of their systems to ensure they were identifying and responding to issues in a timely manner.