The Office

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 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 governance at the service.

This service scored 50 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

There were limited opportunities for managers to share their vision and direction with staff. Staff meetings were held infrequently and there was no system for regular face to face supervision. There were no processes to gather feedback from stakeholders or enable them to contribute to the development of the service. The provider had not recognised the way in which the service was managed meant there was a risk of a closed culture developing. No actions had been taken to mitigate this risk.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

Managers were not confident about the processes and systems required to run the service effectively. They relied on initial care plans developed by the commissioning authority when people started using the service. There was no system for developing their own care plans and associated risk assessments. Although people had person-centred plans to reflect their preferences and goals these did not cover any medical needs or needs associated with distressed behaviours. One person had recently been admitted to hospital, the registered manager was not aware of the requirement to notify CQC of this event. The registered manager was unable to tell us what people’s commissioned hours were. They had to look this up in local authority care plans which they found difficult to locate. We were not assured care was arranged to meet needs as defined by commissioners.

Staff, relatives and an external professional all told us they did not routinely have contact with the registered manager and communicated more frequently with a director of the service.

The provider did not foster a positive culture where people felt they could speak up and their voice would be heard.

The service was a family run organisation. The director, nominated individual and registered manager were all related. This had not been identified as a risk. There were no clearly defined routes for staff to raise concerns internally about the management team. Minutes from a recent staff meeting stated; ‘Staff are not to go to [Director Name] or [Nominated Individual Name] anymore.’ There was no nominated safeguarding lead.

A policy for staff who were in a close personal relationship working together did not detail what safeguards should be put in place when relatives worked a shift together with no other staff present. No risk assessments had been completed covering this area.

Following the inspection the registered manager developed risk assessments to cover when staff worked together and when a person using the service was related to a staff member.

The provider worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they were well supported at work and were treated fairly. If they needed to work in a flexible way alterations to working patterns could be made.

Staff meetings and supervisions were infrequent. However, staff said they were able to approach the director for support and guidance if needed.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider was not developing their own risk assessments so we could not be assured risks were quickly identified and action taken to mitigate risk. There was no system for identifying trends or themes following incidents. Staffing arrangements did not consistently ensure people had quick access to staff when needed.

People were not receiving their commissioned level of support as weekend staffing arrangements were insufficient to provide 1:1 care. The provider’s quality assurance systems were ineffective as they had failed to identify this issue prior to our inspection. There was no system for recording when people had received 1:1 support from a member of staff, and for how long. This meant we were unable to check if people were receiving support in line with their commissioned hours during the working week.

There were no records to evidence managers were monitoring the quality of the service. Spot checks and supervisions were not taking place. Recruitment processes were unsafe. There was no business continuity plan to guide staff on the action to take in an emergency.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

CQC had not been notified of events in line with legal requirements.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Care plans had not been developed by the service to include any new information about people, or their specific health needs. This meant information could have been no longer relevant or outdated. Systems to monitor the service in order to drive improvement were not effective. There was no schedule for auditing. Staff did not receive regular supervision where they could highlight any training needs. However, throughout the assessment the registered manager responded positively to feedback and demonstrated a willingness to improve.