Passionate About Care

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 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.

The provider was previously in breach of the legal regulation in relation to good governance. Improvements were found at this inspection and the provider was no longer in breach of this regulation.

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 service 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. Staff knew the aims and values of the organisation. The service sent out monthly newsletters to staff to update staff of any updates to the service, information and staff updates, which also included staff achievements and rewards.

The service 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. Staff felt supported by the manager and senior team. The manager was going through the process of registering with CQC to become the registered manager for the service. They told us, “In terms of leadership, I’ve spent time restructuring both the office and field teams. We've welcomed two new supervisors and a business development lead, which has brought fresh energy and support to the team.” One staff member told us, “This is the best managed care company I have worked for the staff genuinely care for the clients and it feels like one big family which I love.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The provider completed surveys of people and their relatives’ views. The provider had appropriate polices in place as well as a policy on Duty of Candour to ensure staff acted in an open and transparent way in relation to care and treatment if people came to harm. Staff we spoke with were happy to speak up for people, always listen to people’s needs and to act on any concerns or needs that people may have.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place.

The service had made improvements in all areas of governance. The service 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. Internal governance procedures were in place with a range of quality monitoring systems including care plans and medicine audits. The manager told us, “Auditing has become a more focused and proactive area of our operations. Each month, I carry out area audits across three key areas: daily tasks, MAR charts, and visit logs. We also review concerns submitted by staff through the app, which helps us quickly spot issues related to incidents, medication, or care delivery. Deployment audits help ensure we have the right carers in the right place at the right time. Currently, I’m working on introducing a weekly whole-business quality audit using the CQC inspection tool, which will help us continuously improve and refine our procedures.”

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. The manager told us how they were planning on strengthening and expanding the service’s connections within the local community. They said, “We’ve recently begun focusing on recruitment to help us expand our services. As part of building a more connected and compassionate community, I’m planning initiatives like coffee mornings for clients and a family fun day for clients, carers, and their loved ones. We're also planning to engage more in local fundraising and networking with professionals and community groups to build stronger partnerships.”

The service focused on continuous learning, innovation and improvement across the organisation and local system. They actively contribute to safe and effective practice. The provider had been working hard following the last inspection and had made improvements. There was an emphasis on continuous improvement with the views of staff and people actively sought both formally and informally. Staff meetings and supervisions showed these were used as a way to make improvements to the service.