Your Quality Care Services Limited (East Grinstead)

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 service 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 good governance.

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 service had a shared vision, strategy and culture

Staff told us they felt part of the team and liked working at the service. A staff member said, “My manager also values my opinions and suggestions. We are able to discuss ideas openly, and I feel that my views are listened to and respected.”

Management demonstrated compassionate and inclusive leadership by listening to staff concerns and providing appropriate support. Whilst the management team were seen as approachable, they demonstrated lack of knowledge and understanding of the requirements of the MCA, record keeping and effective monitoring systems.

The service held regular team meetings and supervisions. This provided staff with an opportunity to discuss the service and people’s support needs.

Staff were complimentary about the registered manager and found them approachable and inclusive. A staff member said, “I feel well supported by my manager. They are approachable, always willing to help, and respond promptly to my phone calls and text messages whenever I need advice or guidance. This gives me confidence that support is always available when required.”

People and relatives were also complimentary about the management of the service. A relative told us, “[The registered manager] has been cheerful, efficient, kind and happy to patiently explain if I or [person] don't understand.”

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

Staff told us they felt confident in speaking up if they had any concerns and knew how to whistle blew. A staff member said, “I feel I can raise concerns or ask questions with my manager and the office team whenever needed, and I know the appropriate procedures for reporting any concerns.”

The registered manager was aware of the importance of supporting staff to speak up.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff confirmed they were treated fairly and were complimentary about the registered manager. One staff member said, “I can honestly say I really enjoy my job, I feel 100% supported by my manager, senior management and other carers. All the clients are wonderful. It’s a really great place to work.” Another staff member told us, “My work place is very inclusive and free from discrimination. We have a wonderful, eclectic range of staff from all over the world.”

New staff completed a health questionnaire form as part of their application process in case any reasonable adjustments at work should be explored.

The service did not always have clear systems of accountability or good governance.

Governance systems in place were not robust and did not identify shortfalls found at this inspection. The provider did not follow their policies regarding medicines, end of life care training and mental capacity assessments. The provider did not work in accordance with the current MCA legislation.

The risk assessments in place did not always include the necessary detail and information on how to support people. These were reviewed and updated in response to our feedback.

Services we regulate have a statutory responsibility to notify CQC about certain events that occur in a service. Notifications were being submitted, as required.

The provider started taking action to address some of the shortfalls during the assessment.

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

People were generally independent in arranging and attending their appointments. Staff supported them if requested.

The provider ensured important information was recorded and accessible to staff, supporting continuity of care and helping services work together effectively around people's needs.

The service 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. They actively contributed to safe, effective practice and research.

The service had an up-to-date continuity plan.The provider held regular meetings across all services to aid learning and improve the quality of service offered.

The provider did not always have a good understanding of how to make improvements happen.Our inspection found a breach of regulation in relation to good governance. The provider made some changes to address some of the shortfalls identified. However, the changes made needed to be embedded into practice and sustained.