Archived: Staffordshire

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

Staff and the management team were person focused. There was 1 instance of an undignified term being used. Staff felt supported in their role and felt able to speak up if they had concerns. Policies were in place to support staff speaking up, but improvements were needed to show the provider evidenced they acted on feedback and acted in response to concerns. Staff felt treated fairly at work. There were governance systems in place to monitor the quality and safety of care, however, these were not always effective at identifying the omissions we found. People were regularly asked for their feedback and people overall had positive feedback about the support they received. The provider had been dedicated to making improvements and learn. However, further improvements were needed to ensure effective recording and monitoring was in place.

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.

Staff we spoke with were compassionate when referring to people and their relatives. A member of the management team told us of a staff recognition scheme with employee of the month and a token of appreciation as encouragement for staff.

We saw 1 example of an undignified term being used in a person’s care plan; it is important people are always referred to in respectful and empowering terms. However, the provider and management team were supportive of staff and had a person-centred focus.

Staff were positive about the management team and felt supported in their role. One staff member said, “We have supervision, every few weeks. The manager is good, they are there if you need.” Another staff member told us, “The managers at the company do get back to me if I need it, they give advice when I need it, they always answer the phone.” The management team wanted to ensure people had access to their information. A member of the management team told us, “Our documentation has improved and is more person centred. Not every company is digital, not all our service users access the internet, we keep paper records for them, so we include everyone.”

The provider asked people and relatives for feedback and an action plan was formulated to address feedback. The feedback in surveys said staff were kind, caring and they were happy with the support they received.

Staff told us they felt able to raise concerns. One staff member said, “There’s an open-door policy, if you’ve made a mistake you can go to them. There’s a place on the system for communication and they say to just write it down and then they might call you and talk to you about it.” Other staff also confirmed they could call the office or speak to management if they felt they needed to.

The management team told us they informed staff of safeguarding and whistleblowing processes as part of their induction and explained to staff their requirement for reporting on any concerns.

The management team were aware of their duty of candour. A member of the management team said, “Duty of candour is transparency and honesty, as humans we error, but we need to be remorseful, honest and transparent.”

The provider had regular staff meetings in place, where they discussed any concerns identified in the management of the service and what actions had been taken to address these.

Staff were also asked their opinion through surveys. Feedback was overall positive although there was some mixed feedback too. While there had been an analysis of the results and there was an action plan in place to address feedback, actions had been ongoing for some time so had not been fully addressed. Some actions had been completed and further feedback in that area had not been received. There was repeated feedback about staff thinking additional training would be beneficial. The nominated individual explained the training staff were requesting was a formal NVQ (National Vocational Qualification) and as these are funded courses, they needed time to, “identify ways to provide this training, enabling staff to continue their professional development and grow within the care industry.”

The provider had a whistleblowing policy in place and risk assessments were in place to reduce the risks of staff who were related working together. The nominated individual told us, “We also offer ‘Freedom to Speak Up’ workshops, which encourage staff to voice their concerns to management. This initiative aims to foster a positive work environment by considering staff suggestions for the benefit of both service users and colleagues.”

However, as the recording of action taken in response to safeguarding concerns and evidence of learning from incidents was not always evident, we could not always be sure this would be effective.

Staff told us they felt well treated at work. One staff member said, “The company is treating us well.” Another staff member said, “The company has been good to me, it’s been good all round.” Another staff member told us, “They treat me well.”

The provider had recruited a staff team with a range of backgrounds and staff had completed training about equality, diversity and human rights.

The nominated individual told us everyone’s care plans and risk assessments were audited in October 2024. One staff member said, “I do feel the company is well run.” Staff confirmed they had spot checks where they were observed to ensure they were supporting people safely.

The provider told us some care plans and risk assessments needed reviewing on a monthly or quarterly basis. However, this schedule was not being followed as some people’s care plans had gone longer periods of time without this being completed. When we asked the management team about this, they confirmed people should have a review either monthly, quarterly, or as someone’s needs changed. They said they were in the process of reviewing files, but this was impacted by them also delivering care calls. Records, such as care notes, care plans and MARs were regularly audited. However, in some instances the follow up action had not been completed, therefore it was unclear if any action had been taken in response to areas they had identified as needing addressing.

We found, 1 person had a relative sign consent on the person’s behalf, but the relatives right to make decisions on behalf of the person had not been checked. The same person’s medicine risk assessment showed the provider did not fully understand the Mental Capacity Act 2005 (MCA), as there was no supporting evidence and it indicated relatives had Lasting Power of Attorney, but this was not applicable for this person. The MCA in place carried out by the provider did not indicate how they had tried to support the person to understand or communicate their choices, therefore, we could not be sure the provider fully understood the principles of the MCA.

Notifications were not always submitted in a timely manner and sometimes the provider had to be prompted to submit these. Notifications are events, such as safeguarding allegations, injuries or deaths, the provider has to tell us about.

There was a monthly management audit in place, reviewed people’s feedback, safeguarding concerns, complaints, staff spot checks and training needs. However, as noted above, we found some omissions or contradictions which had not been identified. Despite this, some systems were effective and there were some clear and detailed care plans in place.

The provider had a policy in place in relation to staff using their personal mobile phones for work purposes, in order to try and protect people’s personal information. Paper records were also being securely stored in the office.

The rotas were well run as people received care which was overall punctual, for the correct length of time and people told us they had a consistent staff team.

One person said they were asked for their opinion about the service, they said, “Someone comes out with a questionnaire, and I fill it in, it asks for scores on different areas. As I’ve had no problems it’s a 5 [top score] for me.” One relative said, “The managers are very good actually, I’ve had good conversations with them.” Another relative said, “We have no complaints, they stay in touch with us, and I can contact them easily.”

A member of the management team told us they were proud as they had not received any negative feedback from a Quality Assurance Form (QAF). A QAF was a form people, relatives or professionals could fill in and send to the local authority to feedback about a service and the provider has the opportunity to respond to these.

Staff did not have any feedback about Partnerships and communities. The provider told us they linked in with other care providers so staff could do team building and fun activities together.

The provider used staff to deliver care who were sponsored by other care services to work in the UK with a visa. We received feedback from a partner organisation that some staff worked over the hours they were allowed to, in line with their work visa.

The provider collaborated with other organisations and professionals to meet people’s needs. However, as we were told some staff had worked over their allowed hours, we could not be sure the provider had effective systems in place to avoid this occurring.

The provider told us they linked in with other care providers so staff could do team building and fun activities together.

The registered manager said, “We try to deliver the best for our clients. We keep aiming, we are not going to tire.” Staff felt there was a learning, rather than a blame, culture. The management team told us staff were supported to have a de-brief following incidents to check they were ok and to identify possible learning.

The provider had been dedicated to making improvements and learn. However, further improvements were needed to ensure effective recording and monitoring was in place. This was the fifth consecutive time the well-led key question had been rated as requires improvement. The provider created an action plan and detailed actions taken in response to our feedback regarding omissions.