Gogomadu Cares Nottingham Office

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 service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 32 (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 demonstrate a clear, shared vision or culture rooted in transparency, equality, diversity and inclusion, or meaningful engagement. There was limited evidence that leaders understood or responded to the needs of people using the service or the wider community.

There was a lack of leadership, management understanding and planning to improve the standard of the service. The service lacked vision and did not have systems in place to monitor the culture of the service or how people were supported. The standard of care people received was dependant on the skills of the individual staff members supporting them with no overall strategy as to how the service would offer consistently good care.

The service manager completed spot checks and competency checks on staff, but the records shared with us showed this member of staff had gaps in their own training records. This created a risk that staff competence was not reliably assessed or assured, which could impact the quality and safety of care delivered.

Team meetings took place; however, the minutes did not evidence meaningful discussion, staff engagement, or shared learning. Records were descriptive and instructional, with limited evidence of staff voice, challenge, or reflection. This meant, meetings were not used effectively to support a shared vision, inclusive culture or staff involvement in shaping service direction and improvement and we found no alternative evidence to support this work taking place in any other areas of practice.

Not all leaders understood the context in which the provider delivered care, treatment, and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience, and credibility to lead effectively, or they did not always do so with integrity, openness, and honesty.

There were many managers in the service, and it was unclear how their roles all fitted into the organisation, especially as there was just 1 person who received a regulated activity. There was no consistently communicated strategic direction to support improvement or engage with local partners. This meant the lack of a shared direction and inclusive culture presented a risk to equitable outcomes, learning, and service sustainability.

The management team were not aware of the areas of concern we highlighted during our assessment but agreed to work on these to make improvements and created an action plan to track each task. However, the time set aside for each task did not prioritise urgent issues. Due to the small size of the service but with several managers and staff it was of concern that the provider was unable to ensure these were addressed or systems implemented to monitor and review standards quickly. This showed a lack of leadership, planning, skill and understanding of business continuity planning by the provider.

During our assessment, we found the provider delivered a regulated activity they were not registered to provide. The leadership team had not recognised or identified this was the case and demonstrated the provider’s lack of knowledge about regulation of health and social care services. This put people at risk and failed to ensure they received safe, effective, and responsive care.

Staff we spoke with told us they felt they could speak up and that their voice would be heard; however, many staff did not provide feedback. The whistleblowing policy contained limited detail to support staff to raise concerns and included language that was unclear and not jargon free. For example, one section stated, “We should lead by example. No one is perfect but it is hard to criticise others if our own practice is shoddy.” This wording could discourage staff from speaking up or whistleblowing, as it may be interpreted as judgemental or placed responsibility on the individual rather than encouraging open, safe reporting. This meant there was a risk that concerns may not be raised promptly, limiting opportunities for learning, improvement, and the early identification of risks to staff and people using the service.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The policy intended for equality, diversity and inclusion contained outdated legislation, lacked current legislation, did not include protected characteristics, and had no review date. There was a separate review sheet for the policies to record this which had been recently reviewed by the registered manager. There was a maternity policy which contained incorrect information as to when staff would be eligible for statutory maternity leave. Inaccurate and outdated policies may leave staff unclear about their rights and protections, increasing the risk of discrimination and staff feeling unsupported.

The provider gave examples of how they supported staff with religious beliefs and supported staff to work flexibly due to family commitments. The provider told us, “We have a zero tolerance to discrimination. We create that culture where everyone feels part of a team… We employ anyone from any background.” The provider was able to describe some examples of inclusive practice that was positive, but its equality, diversity and inclusion policies were outdated and underdeveloped, which increased the risk of inconsistent practice and could negatively impact staff confidence, wellbeing, and fairness across the service.

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.

Although a training matrix was in place, there was a lack of oversight to ensure staff had the right skills and knowledge to carry out their roles safely. This meant the person was being supported by staff who did not have had the necessary training. Competency records were not detailed enough to identify gaps. Records could not clearly evidence that staff had consistently received training, or competency checks in areas linked to people’s clinical needs.

All policies we reviewed did not contain sufficient detail, were outdated, incomplete, and did not reflect current legislation or guidance. Gaps and inconsistencies within recruitment records had not been identified or addressed prior to our assessment, or during the providers audit processes. We requested assurances that the provider would take immediate action to address the safety concerns. We were not assured that timely and sufficient action had been taken to protect people from the risk of harm.

The provider failed to comply with their duty to notify CQC of notifiable events. Significant incidents were not reported as required, which limited regulatory oversight and demonstrated ineffective governance and a lack of understanding of statutory responsibilities.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Where there were complex care tasks which required specialist input, the provider could not evidence that the required collaborative work with a designated point of contact took place. The nature of the care tasks meant that there needed to be strong partnership relationships with external professionals to keep the person safe. We received concerns from 3 professionals or organisations we contacted regarding working with this provider or linked to elements of care being provided. This meant the person was at risk of harm from not having the necessary partnership links in place.

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. They did not actively contribute to safe, and effective practice.

The failure to ensure robust governance and oversight meant there was no opportunity to learn and improve the quality of care provided for people. There was no evidence of a lessons learned process following incidents or concerns. After we raised our initial concerns with the provider about less urgent issues, we were supplied with a ‘lessons learnt’ document and an action plan. They told us they planned to create a service improvement plan to work towards continuous improvements. However, after this when we raised more urgent concerns with the provider, we did not always receive sufficient prompt responses.