Mercy & Clara Healthcare Ltd

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.

This is the first assessment for this newly registered home care service. This key question has been rated 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.

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. People and their relatives felt listened to by the provider. Staff felt their views were valued and respected. People and their relatives were encouraged to provide feedback on the care they received. Staff and leaders demonstrated a listening culture and were open to learning and implementing improvements. The registered manager was keen to ensure all staff knew the values and ethos of the company which was based on shared understanding, compassion and transparency.

Although the provider had inclusive leaders who understood the context in which they delivered care, treatment and support, management did not always have the knowledge or understanding to ensure the service provided safe and effective care in line with best practice guidance. For example, there were shortfalls around best practice in relation to care planning, medicines management, assessing risk and people’s mental capacity. However, feedback was very positive about the management team and their ability to work with people and their relatives and had a culture of listening and learning to make improvements.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were confident they would be listened to, and their voices would be heard. The provider had a clear whistle blowing policy. Staff could raise concerns and the information about how to do this was available. Staff meetings took place, and staff had the opportunity to share comments and give feedback.

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. Staff provided positive feedback about their experience of working at the service and told us they felt equally treated and supported by management. They told us they felt valued and respected in their roles. One staff member said, “We work as a team and support each other. Because the registered manager is part of the care team, we are all treated the same way.”

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. This was in relation to people’s medicines records, and how the provider recorded consent in line with best practice. Additionally, care planning audits had not identified the shortfalls we found at this inspection regarding the level of detail and assessment of risk within care records. Whilst we found no evidence people had been harmed, the registered manager acknowledged the shortfalls and told us they would look to address this immediately. Despite this, a relative and staff confirmed the management team were part of the caring team which meant they attended regular home visits to monitor the service.

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. The registered manager was not engaged in networks within the health and social care for support and guidance. However, they worked collaboratively with the GP and district nurses when needed.

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, and effective practice. For example, the provider did not have effective systems and processes in place to evidence they were learning form incidents. However, staff gave positive feedback about the management team, noting they felt involved in the service and their ideas for improvement were welcomed and listened to.