Passion 4 Care

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 remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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.

People told us they felt respected and treated with dignity by staff. A relative told us, “[Staff] tell [person] what they are doing and ask permission... They know about [person’s health conditions] and the fact that [person has broken their bone], so [staff] are very gentle with [person].

The provider promoted a positive culture in the service and staff told us they felt supported and valued by the management. One staff member told us, “The best thing about working for Passion 4 Care is the support we get, the client progression and our need to grow.”

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.

People and relatives told us they were involved in their care and had regular reviews and received surveys to gather their feedback. People and relatives told us the provider was receptive to feedback they received, and this was acted upon. One relative told us, “We get regular surveys. They rang me and I [made a suggestion about the care].” Care staff confirmed the relative’s suggestion had been successfully implemented for people they supported.

The provider held regular team meetings, training sessions, supervisions and appraisals with staff to ensure staff felt supported in their roles. We saw evidence of this taking place and staff confirmed this too. A staff member told us, “The company listens to us - they don’t avoid us, they take us seriously and they consider what we say.”

The provider understood their duty of candour and explained their how they investigated complaints and shared any learning with all staff. We saw staff received memos with things they needed to be aware of.

The provider enabled people, relatives and staff to feel comfortable to speak up, as they knew their views would be listened to.

The provider told us of the ways in which people, relatives and staff could share their views and this was confirmed by the feedback we received. We saw the provider’s analysis of the latest staff survey and the actions implemented following this.

Staff told us they were aware of the relevant policies for whistleblowing and speaking up. We saw copies of these policies.

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.

Leaders ensured people with learning disabilities and autistic people were supported in line with the principles of Right Support, Right Care, Right Culture by ensuring staff received relevant training and ensured people received person-centred, safe, and respectful care.

Staff spoke positively about the management team and how all staff worked well as a team. One staff member told us, “They [Passion 4 Care] have a good team, and everyone works hand in hand. People are safe.” The manager explained, “I try to be personable to staff, and they can fetch me when they need anything.”

People and relatives told us how they felt listened to by staff and management as well as their confidence in management. One relative told us, “I speak to [staff member], they would definitely sort any problems.” Another relative told us, “[Staff member] seems to have everything well managed from top to bottom.”

The provider did have clear responsibilities, roles, and systems in pace to support the good governance of the service. However, some of the systems in place did not effectively support in identifying risks. Where identified, the provider did act on information about risk, performance and outcomes, and shared this with others when appropriate.

We identified some inaccuracies in people’s care documentation which had not been identified through the provider’s audits as well as missing ‘when required’ protocols for people’s medicines. This meant the provider’s audit tools were not always used effectively in identifying these discrepancies in people’s care documentation.

The provider was completing notifications in line with their legal requirements, to inform us of any significant events within the service. However, there was an occasion where an event was not notified to us and when documentation was not available to view in the office address due to an unexpected incident at the location.

The provider worked well with other organisations to make sure people received well-coordinated care, as well as sharing information to improve services for the people who were receiving them.

People and relatives told us staff communicated with them and shared relevant information with them. One relative told us, “If there are any problems, they ring me.” Another relative told us, “We have [a care folder] and they [staff] update it daily and I read it.”

Staff told us they worked with other professionals to make sure people received the support they needed. One staff member told us, “We are all working as a team with the professional and have to speak with the district nurses to monitor people with diabetes.” Another staff member told us, “Collaboration is key; we give our clients the maximum attention.”

The provider worked with the local authority to make improvements to their service. We saw referrals had been made to other organisations, such as Occupational Therapy referrals, to request appropriate support to keep people safe in their own homes.

The provider was passionate about learning and improving their service. They supported staff training and development to improve the outcomes for people being supported as well as creating opportunities for staff to develop their skills and knowledge.

Most people and relatives told us they felt comfortable and safe with staff and the way in which they were supported. One relative told us, “They use the hoist to transfer [person], and you can tell that they have been trained on hoists and safe handling as [person] feels very safe. We get 2 [staff members] and they come at the same time.”

Staff shared how they felt encouraged to learn and develop in their roles. One staff member told us, “Passion 4 Care have encouraged me to complete [specialist training]; the training is good, and it is useful - I learn something new every day.”

The provider explained how they had a 'culture of learning' and how they would investigate concerns and learn from them. The provider told us, “We take a precautionary approach; if there is an issue with one staff member, we look across all staff.” We saw staff surveys had been completed and analysis of themes to develop action plans for the service. We will review the effectiveness at our next inspection.

The manager told us, “If we identify issues, trends and themes we identify the level of information and pass it across to staff by monthly and weekly memos and reminders.” We saw evidence of memos being sent to staff to alert or remind them of important information.