AFG Community Liverpool City South

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.

The provider was in breach of legal regulations in relation to good governance. Concerns relating to the implementation of the Mental Capacity Act and due regard for people’s rights under the Deprivation of Liberty Safeguards legislation had not been identified or addressed by the quality assurance systems in place.

‘Right support, right care, right culture’ guidance was not always followed to ensure people with a learning disability and/or autism were supported appropriately in a way that maximised their independence.

The governance systems in place had not identified people’s daily records indicated they did not always receive the amount of personalised support considered necessary by the Local Authority in order to meet social and recreational needs.

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 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. There was good promotion of equality, diversity and inclusion within the organisation. Staff had access to equality, diversity and inclusion policies and a range of events and forums were available. A staff member stated, “We have access to Viva Engage social network, can post photos about what we have been up to, interact with other houses, post acknowledgements etc. It’s very interactive and positive.”

Staff discussed the recent changes to staff teams within some services and how this has had a positive impact on the culture amongst teams. Feedback regarding management was positive and some comments included, “Management listen to us and take on our feedback. There is a good staff team and good leadership.”

Leaders told us they were committed to ensuring staff felt supported, listened to and they promoted a positive culture.

We spoke with registered managers, team leaders and support staff within services as part of the assessment. A team leader spoken with stated, “The registered manager provides great support. The company acts on any concerns and lessons are learnt when things go wrong. There is a safeguarding lead for the organisation.”

Staff felt supported by team leaders and managers and were positive about the organisation and the support they received. They liked team leaders were hands on in services and were looking forward to the implementation of the new electronic care management system.

The knowledge and understanding of the leaders of the service in respect of the MCA, DoLS legislation and Right culture legislation for people living with a Learning Disability and/or Autism was not as robust as it should be. As a result, organisational practice did not ensure people’s human rights were fully protected.

Leaders told us they were committed to ensuring staff felt supported, listened to and they promoted a positive culture.

We spoke with registered managers, team leaders and support staff within services as part of the assessment. A team leader spoken with stated, “The registered manager provides great support. The company acts on any concerns and lessons are learnt when things go wrong. There is a safeguarding lead for the organisation.”

Staff felt supported by team leaders and managers and were positive about the organisation and the support they received. They liked team leaders were hands on in services and were looking forward to the implementation of the new electronic care management system.

The knowledge and understanding of the leaders of the service in respect of the MCA, DoLS legislation and Right culture legislation for people living with a Learning Disability and/or Autism was not as robust as it should be. As a result, organisational practice did not ensure people’s human rights were fully protected.

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. A rewards and recognition scheme for staff was in place, this included annual awards for staff success and peer recognition. Staff had access to an equality, diversity and inclusion hub to act as a one stop shop for resources.

Staff spoke positively about workforce equality, diversity and inclusion. One team leader stated, “There is an excellent rewards scheme and recognition for staff who have worked for the organisation for many years.” Further examples, included flexible working, and the ‘You Matter’ application for the internal benefits programme.

The provider had recruitment, flexible working and equality and diversity policies and procedures in place. Surveys and listening groups provided the opportunity for staff to feedback and share their experiences. A range of equality and diversity training was provided to staff with annual refreshers.

The provider had systems in place for the oversight of risk and review of quality. However, the systems had not identified breaches in compliance found at this assessment. Shortfalls in the failure to follow the Mental Capacity Act and DoLS legislation resulted in restrictions being imposed on people without evidence these restrictions were necessary, proportionate and in the person’s best interests. Restrictive practice audits were observed and completed, however, these failed to identify the shortfalls and as a result restrictions continued to be imposed. We discussed these shortfalls with the provider, who took immediate action to address these issues.

Records did not always evidence people were accessing the community as directed within support plans. The systems in place had not identified this as an area for improvement. The provider shared additional records following the onsite assessment for evidence of community hours, however, these still did not match the commissioned hours from the funding authority. Improvements were required to ensure people were in receipt of the support they needed to maintain their emotional wellbeing and social engagement.

Governance systems had not identified inconsistencies with PEEPS or evacuation times. Audits had been carried out on records and the running of the service; however, these audits had not identified the concerns we found during the assessment. This was required to ensure people were protected from risk and safe care was being delivered at all times.

The provider was introducing a new electronic support planning system. This was being phased in slowly across the service with training dates planned for staff. The provider was confident the new system would improve overall oversight of the service. The registered manager understood their responsibilities in relation to their regulatory requirements around notifiable incidents.

Relatives provided positive feedback on partnership working and comments included, “They keep me informed of [person] appointments and update with his goals and I get a copy of everything.”

A business continuity plan was in place, with yearly reviews to include planning for emergencies and significant events.

Feedback from partners was positive and reflected how the provider worked in partnership with commissioners and the local safeguarding teams. Managers understood their duty to collaborate with external partners and stakeholders.

Whilst the provider had a desire to focus on continuous learning, innovation and improvement across the organisation, in practice this did not always take place. Models of care were not aligned to best practices guidance, including 'Right support, right care, right culture'. Whilst we did identify shortfalls during this assessment, the registered manager was responsive to our findings and acted on key areas of improvement.

Staff provided positive feedback on improvements to the culture of the organisation. One staff member stated, “Shift times have changed following feedback from staff, this works better now. We are a new staff team and work well together; management listen to us and take on our feedback.” Relatives echoed the improvements that have been made to include, “It's very much improved. They listen to me now. The whole attitude is much better, some people have gone. It's a happy place.”

There were systems in place to measure the outcomes for people being supported, this included spot checks and feedback gathered from people using the service through surveys. Staff team meetings took place regularly and detailed minutes were recorded evidencing subject areas with a focus on learning and improvement.

New digital systems for electronic care management were in the process being introduced at the time of the assessment. The provider had developed a tech lending library to support people to access various types of technology to assist with everyday living and improve quality of life or independence.