Advance Healthcare (Pine Court)

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 under the previous provider, 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 systems at the service.

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’s vision for the service was not universally understood by staff. Leaders told us they had a strategy in place which outlined the strategic objectives of the organisation, and this had been shared with staff. The provider’s vision was incorporated into their polices however, when we spoke to staff, they were not familiar with the vision content and could not give examples of where this was used within the context of their role.

Not all leaders had the skills, knowledge, experience and credibility to lead effectively. The registered manager told us the team leaders had responsibility for ensuring action was taken when things were identified which required improvement. We found where systems in place were identifying things needed improving, action had not been taken to address this. There were checks in place to review care plans, however they had not identified where care records indicated a best interests discussion should have been documented following a decision specific mental capacity assessment.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had systems in place to ensure staff could raise any concerns. Staff were aware of how they could speak up and felt confident they would be listened to. There was a policy in place which supported this.

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 told us they felt the provider was supportive and made adjustments to their role when needed. The provider told us they had an equality and diversity policy in place. There was positive action taken to ensure diversity, for example the provider had made a commitment to ensure gender balance within the board of directors.

The provider did not always have clear systems or good governance in place or working effectively to drive improvements. Systems were not effective in ensuring the safe administration of people’s medicines. The registered manager told us there were regular checks in place on the medicines administration system carried out by the team leaders. Records showed checks were undertaken every month. These checks had identified where 1 person had not received their prescribed medicine for over a month as this was not available. However, despite being identified, no action had been taken to raise this with the registered manager, secure the medicine for the person or seek an alternative from their GP. In another example the checks had identified an error with the date of administration of controlled drugs, however there was no documented action taken by the leaders to ensure this did not happen again.

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 provider had policies in place which set out a stakeholder led approach to corporate governance and was committed to understanding the needs of all stakeholders when they designed systems and made decisions. The registered manager told us they worked in partnership with a range of different professionals to deliver people’s care. Partners told us they felt the provider worked with them in an open and transparent way.

The provider’s systems did not always enable continuous learning and improvement. The registered manager told us there were regular checks in place to learn from audits and enable improvements to the system. We saw there were systems in place to check care records which had identified where improvements were needed for example, where there was no record of a lunch time call taking place for 1 person. However, there was no documented action taken to find out why this had happened and draw learning to prevent reoccurrence.