16 Westmoreland Road Also known as Quality of Life Homecare 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 good. At this assessment the rating has changed to requires improvement. This meant the governance and management of the service did not always support the delivery of consistently high-quality, person-centred care. The service was in breach of legal regulation in relation to good governance.

This service scored 62 (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. There were processes in place to promote a positive culture for staff, carers and the people they supported. The provider set out their approach for supporting a person with a learning disability, based on the principles of promoting choice, independence and person-centred care. Almost all the people and relatives we spoke with were positive about the service and their experiences. A relative told us, “The service is excellent.” Staff also told us there was a listening culture. Their comments included, “I am always feeling good when I am at work, I love my job" and “They ask for our input on whether there are any improvements to make and we can share ideas. I would say it’s a positive culture.” Recent staff meeting minutes showed the managers set out expectations and directions for the service. The managers said, “Our greatest pleasure is feedback that carers are caring and meeting the needs of people.”

The provider had capable leaders 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. The provider had recently recruited a new deputy manager to develop and support the management team. People and staff described the leaders as approachable and said there was an open‑door culture. Staff comments included, “I’m always given a listening ear” and “They do show they care. They listen to my questions and concerns. They help me when I ask for it.” Staff described the registered manager positively and said, “The [manager] is good at asking how we are and making sure we are ok”. A staff member told us, “The manager knows us well. When I see them, they always ask about me, my family and ask. how things are going. They always ask if you are happy and ok. I do feel valued."

The provider worked to create a positive culture where people felt they could speak up and be heard. Staff said they felt able to raise concerns if they needed to and they would be listened to. A staff member told us, “I would tell the manager. They have a system in place to keep my identity anonymous. I know they action these concerns immediately.” There was a whistleblowing policy in place to support this. Another staff member told us, “We do have freedom to speak up. We have a straightforward whistle-blowing policy. They have acted effectively in my experience."

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. A care worker said, “I feel valued and respected by my colleagues. I don’t know anyone that’s unhappy or feels discriminated.” Staff said they felt listened to, for example in meetings with their supervisor and team meetings. The provider was using a survey to gather feedback from staff about the service at the time of our inspection. The managers said they would use learning from this to continue to make improvements.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance at the time of our assessment. They did not always act on the best information about risk, performance and outcomes to ensure people always received a safe and effective service.

The provider’s systems to manage current and future performance had failed to proactively analyse service information to identify good practice requirements or emerging trends. The arrangements had not enabled the provider to always ensure daily records provided a complete and contemporaneous records of people’s care, that the service was always worked in line with the Mental Capacity Act, and that appropriate oversight and supervision of all staff was maintained. There had not been adequate understanding and implementation of appropriate medicines management arrangements to ensure this was always in line with practice requirements. We also found an instance when the provider had investigated a safeguarding concern that had not been reported to CQC. A provider must submit statutory notifications without delay and provide updates when additional information becomes available. The provider conducted a range of checks and audits to monitor the quality of people's care. These included spot-checks on staff when working in people's homes to monitor their performance and staff confirmed these took place. However, records showed these were infrequent for and sometimes only annually for some staff. The provider’s systems for monitoring of staff supervisions had not ensured appropriate records of these were always in place to demonstrate they were held regularly. It was also not clear if the provider always visited people who had no relatives to help advocate for them when checking whether they happy with the service and it was meeting their needs. While the provider had taken prompt action to address concerns after we raised them, these issues together demonstrated significant shortcomings in the provider’s systems for identifying, capturing and managing service risks and issues.

We saw the provider had recently set out a new strategic initiative requiring staff teams to implement service improvements and report back to regular management meetings. This focused on increased quality monitoring activities, such as service reviews, more spot-checks, medicines support audits and gathering feedback from people and relatives.

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

The service worked with other partners such as healthcare professionals and statutory services to meet people’s needs. For example, staff liaised with relevant professionals when people’s needs changed and requested referrals for occupational therapist involvement or a reassessment of a person’s care needs.

The provider had practices in place to develop the service, but these had not always been applied consistently so the quality of the service continuously improved. There was limited evidence managers consistently reviewed key areas of the service, such as incidents, safeguarding concerns and spot-checks over time. This limited their ability to identify emerging themes and trends, take proactive action and drive continuous improvement. The provider had taken some improvement actions after we discussed this with them, which the provider acknowledged.

However, the provider did have a service development plan in place that they were implementing, which set out their vision and values. They had recently invested in new systems, such as a digital care planning and recording systems. A member of staff told us, “It’s much better than the written records. Things run smoother and the care is tracked better.” Staff said they were encouraged to make suggestions and said, “I feel they listen and incorporate our points over time.”