Aim Up

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 inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant we identified some shortfalls with the governance of the service. The provider was not always notifying the CQC of incidents in the service. This was a breach of regulation. The management team had identified shortfalls in the service and were aware of concerns from relatives and professionals. They had developed an action plan. Some improvements had already been implemented however, further time was needed for the actions to be embedded so their effectiveness can be assessed in line with current best practice guidance right support, right care, right culture. Some of the shortfalls we identified during the assessment had not been identified by the provider. This was a breach in legal regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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. The nominated individual and service manager discussed with us the comprehensive training programme they had started to deliver to the team leaders.

Staff were very complimentary of the management team and the changes made since they had been in post. One staff member told us; “I have been with Aim Up for a couple of years now, and I can confidently say that the new management, which took over less than a year ago, has positively transformed our policies. These changes have significantly benefited both the individuals we support and our team. As the system continues to progress, I recognise the ongoing improvements being made in all supported living houses and domiciliary care services. Regular training and support for staff are also being prioritised, ensuring we deliver high-quality services and provide the best support for all the people we work with.”

Another staff member told us; “As you will be aware we have had a number of changes within the management level within Aim Up, which has recently in my opinion led to a big improvement in different areas such as medication. The recording and storing has been improved. We have had a change in the senior team. I am personally looking forward to what the future brings for this organisation as I can honestly say the improvements being made at present were very much needed. …in the last 6 months I've had regular supervisions without having to ask for them. We are receiving weekly memos from the CEO (Chief Executive Officer) to keep us informed on the changes being made and general updates, so staff are all aware. If something needs looking at or fixing or replacing, it’s happening in a timely fashion.”

Staff were aware of their roles and responsibilities in relation to safeguarding and whistleblowing and felt confident to speak up and escalate any concerns outside of the organisation. Staff told us they felt listened to by the management team and could raise concerns, make suggestions and provide feedback. One staff member told us: “Any concerns we have had in the last 6 months have been looked into and addressed or are being worked on. I feel we are being listened to.We recently had an all staff meeting in which the CEO (Chief Executive Officer) gave us staff the opportunity to give our ideas. We completed an exercise to come up with key words that we find important with in our role, and they would work those words into the principles of Aim Up. This made me feel we were being given a voice, and we were also being listened to.”

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not have effective governance systems to identify and drive improvements at the service.

We identified through looking at the service’s safeguarding log that not all allegations of abuse or incidents of police involvement were reported to CQC. We discussed this with the provider who was going to look at updating their policy and review all their safeguarding and incidents and accidents and submit any notifications retrospectively. This was not identified through their current governance systems.

This was a breach relating to the notification of other incidents.

We identified people’s care records were not always fully completed, for example, with records missing for the support provided, particularly where people were supported on a 1:1 basis. This had not been identified through the provider’s monitoring systems. The audit of people’s care records was an area of development identified in the plan for implementing a new governance system.

The medicine related shortfalls, missing PRN protocols, body maps not being in place, risk assessments missing, were not addressed through the quality improvement plans the service had implemented as part of the work they were doing to improve their medicines management.

Shortfalls in the fire risk management, infection prevention and control, robustness of policies and procedures and improvements to training records had also not been identified by the provider’s own quality assurance systems.

We took into account in our assessment of the service that the management team continued to be proactive in improving the service. Further time was needed to complete the planned actions and develop action plans further before we could judge whether the provider's improvement plan had been effective in implementing and embedding all the improvements and the impact on the quality of care people received. This was a breach of regulation relating to good governance.

The management team continued to work on implementing identified actions and introducing new systems and processes, this including a new system of governance and quality monitoring of the care and support provided. They were planning their service improvement plan for 2025, this including the feedback sought from staff.

A monthly quality meeting was taking place to ensure recommendations from people, staff, external professionals and other stakeholders were gathered into one plan.

The service had engaged with the staff team, people and their representatives to seek feedback which was going to be included in their development plans going forward.

The provider had a business plan in place to ensure sustainability of the service and address any identified challenges.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They were in the process of encouraging creative ways of delivering equality of experience, outcome and quality of life for people. They were starting to actively contribute to safe, effective practice and research.

Since the new management structure of the service had been in place, they had been on a journey of learning in relation to the improvements which were needed to the service, so people received good quality care and support.

Learning was shared with staff, for example through team meetings and memos, which staff found a useful tool for keeping them updated with what was happening across the different locations.

The nominated individual told us; “every day we are still learning, medicines is the biggest learning”. One of the trustees told us they were really impressed with the team because they had a lot of actions set by the local authority to complete and they coped with them very well.

The service manager and nominated individual were open and welcoming of our feedback and took swift action to remedy some of the shortfalls during the assessment.