Das Care 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 provider was previously in breach of the legal regulation in relation to governance at the service. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

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 consistently demonstrate a clear vision, strategy and culture centred on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

At our previous assessment, we found the provider had not set any organisational values to guide staff on the core principles of the service. During this assessment, staff were able to describe the service’s visions and values, demonstrating some improvement. However, these values were not consistently reflected in practice.

People did not always receive care that met expected standards, and gaps in records, oversight and quality assurance limited the provider’s ability to demonstrate that care was consistently person-centred and reflective of people’s assessed needs and preferences.

Although feedback was sought from people using the service and their relatives, discrepancies in survey records, feedback processes and quality assurance meant opportunities for learning and improvement were not consistently identified, acted upon, or reviewed for effectiveness.

However, the provider described a culture that promoted equality, diversity and inclusion, where staff were expected to treat one another with respect regardless of religion, culture, age, sexuality, or background. Staff described the management team as approachable and supportive, and available to listen to concerns and provide guidance when needed.

The provider did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

At our previous assessment, we found poor leadership at the service, which failed to drive the improvements required. During this assessment, although we found some improvements, we identified 2 regulatory breaches and areas of concerns relating to safe care, staffing, recruitment, record keeping, including outdated consent records, the scope of feedback sought through satisfaction surveys, and governance. This demonstrated the provider had not consistently identified, monitored and taken action to ensure that people received care which met legal requirements. These findings raised concerns about the provider’s ability to implement, embed and sustain the changes necessary to achieve and maintain compliance.

However, feedback from people and relatives remained overwhelmingly positive. A relative said, "They keep their eye on [person] and there are clear lines of communication which is very good.”

Staff also shared positive feedback, a member of staff said, “I find senior management approachable and supportive, and I try to reflect this by encouraging open conversations.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

This was supported by a Freedom to Speak Up (whistleblowing) policy, which was available electronically and accessible to all staff.

Staff were positive about how the management team engaged with and involved them and said they were approachable and responsive. One staff member told us, “I feel comfortable speaking up, and concerns are taken seriously and acted on.” Another said, “Staff are encouraged to shared ideas and suggest improvements, such as recommending new activities or improving communication during shifts.”

The provider had completed a staff satisfaction survey, although staff engagement was limited. Survey findings were reported for 5 staff members; however, only 4 completed surveys were shared with us, and some pages were missing. This limited our ability to fully verify the reported findings. However, the feedback available for review was positive.

Compliments and complaints records demonstrated that feedback was captured and concerns were appropriately addressed.

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.

The provider told us they treated their workforce equally and promoted an inclusive working environment. No concerns relating to discrimination were identified during the assessment, and staff had not raised any concerns in relation to equality or inclusion. The provider also told us they supported flexible working arrangements where required.

A staff member told us, “Staff are treated fairly, respectfully and equally.”

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.

At our previous assessment, we identified significant concerns regarding governance and oversight, including ineffective arrangements for monitoring risk and service quality. While the provider had implemented additional governance processes, these were not yet fully embedded or effective in providing assurance and driving sustained improvement.

The provider’s governance systems for auditing the service were ineffective in identifying or addressing areas for improvement, which resulted in people being placed at risk of receiving unsafe and inappropriate care.

The provider’s governance framework outlined a programme of comprehensive quarterly audits; however, we did not receive evidence that all these audits had been completed. The provider submitted 1 audit covering key areas such as safeguarding, risk assessments, compliments, concerns and complaints, recruitment, medicines and care planning. Despite the auditing system in place, governance arrangements were not fully effective, as they failed to identify the concerns we found relating to people’s care plans and associated records, including risk assessments, medicine records, staff training records, and recruitment documentation.

Management meeting records did not consistently record attendees, actions, or responsibilities, limiting accountability. In addition, the Business Continuity Plan was only updated following issues identified during the assessment, demonstrating the need for more effective oversight and review.

The provider continued to use the same electronic care management system; however, its functionality was not being fully utilised to support accurate and effective care records. Several key ‘summary and outcome’ sections remained incomplete. Although care plans recorded that reviews had taken place, records did not consistently evidence the outcome of these reviews or any resulting changes to people’s care and support needs.

Risk management arrangements were not always effective, risk assessments were not always accurate, comprehensive or reflective of known risks, and care records did not consistently provide staff with clear guidance to support safe, person-centred care.

Training records did not provide a clear overview of staff compliance, making it difficult to determine whether all required training had been completed and remained up to date.

The provider advised there had been no missed or late calls and told us they received live monitoring data. However, the call monitoring records submitted were difficult to interpret, which reduced their effectiveness as a tool for oversight and monitoring.

However, some of the provider’s policies and procedures incorporated guidance relevant to supporting people with a learning disability and autism. This demonstrated that governance systems were informed by current best practice and would support staff to meet people’s needs effectively, should the service provider this specialist support in the future.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

At the start of our assessment, we requested contact details for relevant professionals to gather feedback on the quality of the service. The provider advised they do not routinely liaise with professionals, and that people and relatives generally arranged referrals for additional health support themselves. As a result, the provider was unable to share professional contacts for feedback. However, the provider did state that on occasions they call a person’s GP on behalf of them, liaise with occupational therapists, district nurses and physiotherapists.

A member of staff told us, “I follow care plans and professional guidance to meet dietary and clinical needs.”

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The service needed to strengthen its approach to learning and improvement to ensure lessons were identified, quality concerns were addressed and improvements were sustained. Evidence provided did not clearly demonstrate how information was used to identify trends, learn lessons, and drive service improvement.

Although the provider had a service improvement plan, it lacked sufficient structure and oversight. Not all identified actions were formally captured within the plan, and there was limited evidence to demonstrate its review or effectiveness.

Following our final assessment feedback, the provider developed their action plan further by including required outcomes, identified actions, responsible staff, target dates, progress updates, and details of supporting evidence.