Complete Care and Enablement Services

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 outstanding. At this assessment the rating has changed to 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 75 (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 leaders of the service had a good knowledge of the provider’s vision and values for the service. Managers were aware the values included being friendly, innovative, person centred and empowering. They explained how they often quizzed staff on the values and each month, nominations were made for colleagues who had gone over and above for people. When proposing colleagues for any awards staff were encouraged to indicate the company values the nominee had demonstrated.

Leaders felt the culture of the service, as well as team morale, was positive. One leader told us, “We are like one big family.” Staff members were also complimentary about the culture within the service. A staff member said, “There is a really good morale within the team; there is a good mix of staff.”

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 registered manager had accountability and responsibility for various services aligned under this registration. Service managers assisted with management and oversight and reported into the registered manager. The registered manager explained how they tried to remain visible within services where possible. They also described ways they remotely engaged with staff, people and their relatives during the working week, for example via emails and virtual chats.

Service managers had strong links with the compliance team and were confident to request their input if required. Managers of the service had a wealth of experience within different care settings and had experience of the roles they were overseeing.Staff told us leaders, including the registered manager, were approachable and ‘hands-on’ managers. They had good knowledge, skills and experience and were willing to cover support shifts if required.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager and a service manager explained there were no current whistleblowing concerns which had been raised to them. They were confident staff would be able to speak up about any concerns.

Staff were aware of what the term ‘Freedom to Speak Up’ meant. They said this was regularly discussed in team meetings. They were aware of the ‘whistleblowing hotline’ which was available to them and would have no concerns raising issues this way.

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 registered manager explained how the workforce reflected a diverse range of backgrounds, cultures and experiences. Leadership was representative of this diversity, and staff spoke positively about the inclusive culture promoted by the CEO of the company. The provider ensured religious events, such as Eid and Ramadan, were recognised and respected within the service.

Following the COVID-19 pandemic, the provider had employed several overseas nurses and they continued to work there. The provider ensured overseas workers were supported both professionally and practically. For example, they had been supported to achieve qualifications in English language and helped to establish bank accounts; financial aid had been provided when needed.

Staff provided examples of how management had made reasonable adjustments to support staff to ensure equality. A pregnant member of staff had been excluded from manual handling duties. Staff also told us fire training had been delivered in the past to a staff member with a hearing impairment; fire alarms in the service were fitted with vibrating sensors.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Management were aware to inform CQC of any incidents or accidents in relation to people receiving a regulated activity and referrals were made to host authority safeguarding teams where potential abuse was identified.

The provider ensured there were distinct responsibilities and accountabilities for staff within services. Service managers led the teams and reported into the registered manager, contributing towards completion of a range of audit tools introduced by senior management and used at a local level to evidence compliance. Medicine audits however, had not identified the anomalies we found on hand-written MARs; we were assured action would be taken in this area.

Team leaders were responsible for the day–to–day running of the service and reported to service managers. Staff told us the registered manager and service manager were visible and approachable. They told us managers visited the location regularly and staff felt comfortable raising any concerns with them. One member of staff said, “[Registered Manager] is really helpful; they take the time out to go through whether statutory notifications need to be sent to CQC or not.” Staff felt well supported and attended regular meetings. A team leader explained how information was cascaded and shared; for example, via regular group supervision sessions with managers, in weekly staff group ‘huddles’ every Monday and monthly governance meetings for leadership.

Staff clearly evidenced financial records for the people we visited. All expenditures had a receipt, all entries were signed, and balances were checked and in line with agreed budget plans. Leaders arranged team meetings which were well attended. Areas for improvement and reminders regarding protocols and staff professionalism were on the agenda of minutes we reviewed.

Staff ensured daily notes were accurate, up-to-date, detailed and legible and managers completed monthly audits of a sample of daily notes. We identified the use of informal language within a set of daily notes we reviewed, and an inappropriate notice on a person’s fridge. We also identified that improvement was required in relation to one person’s documentation due to gaps on a monitoring form, between 1 to 5 November. Daily interactions had not always been recorded or did not correspond with daily notes made by staff. For example, on the monitoring form the person’s emotional state was consistently described as calm and relaxed but this did not always accurately represent the person’s mood based on entries within daily notes made by staff. We discussed the anomalies within daily notes and documents with managers during formal feedback and were assured this would be addressed with staff and in additional training sessions.

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. Involvement with local authorities, commissioners and health professionals was evident. Good working relationships and collaborative partnerships were established. Feedback received from partners we contacted was limited but very positive. One commissioner of services considered the provider to be responsive when asked for information and updates on progress; a local authority professional said, “I have always found the senior management team approachable, friendly and compassionate about their clients.”

Staff told us they had good relationships with partner organisations such as the local authority and the integrated care board. Staff said they had relationships with local community centres and were well integrated into the community, however not everyone they supported chose to engage with activities on offer in the community.

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.

Ongoing refresher training for staff contributed to safe, effective care. Staff developed their own skills and could also support, train and mentor new colleagues. The culture was an open one in which staff could ask questions and were supported to reflect on their experiences.

The Health and Care Act 2022 introduced a statutory requirement that providers must ensure staff receive learning disability and autism training appropriate to their role. The provider was aware of their responsibilities with regard to Oliver McGowan training and was meeting this requirement; staff we spoke with displayed a high degree of understanding and had an excellent awareness of the challenges faced by the people they supported. Systems and practices in place supported and encouraged openness and learning for the benefit of the people receiving care and support.