Cathrolls' UK Limited

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 service. This key question has been rated 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. The management team were passionate about the service and wanted to ensure people had good quality care and improved outcomes. The provider’s statement of purpose stated ‘Cathrolls’ UK Limited aim to assist those in need of care, to live as safely and comfortably as possible in their own homes. We will do this by actively encouraging the independence, dignity, privacy, choice and wellbeing of all our Service Users. Our principal belief is one of delivering a continual high quality service and developing relationships that actively encourage our Service Users own wellbeing.’ We found that the service was achieving their aims. The staff gave positive feedback about the culture of the service. Staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. A staff member said, “So far so good with support from managers.”

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. The management team knew people well and were passionate about making sure people received good quality care. Staff understood their responsibilities to meet regulatory requirements. The registered manager was supported by the nominated individual for the provider.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Complaints processes were available. A relative confirmed the management team were responsive and accessible. Staff confirmed they were invited to meetings and encouraged to contribute. Staff felt listened to. A staff member said, “I will give them a score of 85 to 90% for responsiveness, to be active and to respond on time.” Staff meeting minutes evidenced that these took place regularly. Staff told us they were encouraged to voice their ideas for improvements and any concerns. Staff knew how to raise concerns with the provider or outside organisations if they needed to.

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 felt they were treated well and supported equally by management. The provider had processes in place to encourage an inclusive culture, and support was in place for staff. Any issues could be discussed openly at staff meetings or during supervision. Staff told us they would not hesitate to speak to the management team if they needed to.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. It was not clear that a robust system of audits and checks were in place to provide the registered manager and provider oversight. Records management required improvement, some records were missing or not completed. Records and filing appeared to be chaotic which was concerning when the service was only providing support to a few people. Audits and checks had been completed quarterly for the last 9 months but no other audits and checks had been completed prior to this. Some policies and procedures had different names of people and services listed in them and had not been reviewed to ensure they were relevant to domiciliary care. Audits and checks had not picked these issues up. The provider had not informed CQC of a change of telephone number for the service. Since the site visit a notification has now been received. Despite these issues, people were receiving good quality care and support and had not been impacted. Staff told us spot checks were taking place frequently.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The management team were keen to build links with partnership agencies and had liaised with the local authority and local integrated care board. The registered manager was involved in forums and events to keep abreast of local and national developments in health and social care.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The registered manager and nominated individual for the provider told us they had reviewed the feedback we gave them as part of the onsite and offsite assessment process and valued this. They were using the feedback to make improvements to the service and to put systems in place to embed the changes.