Geocare Services 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 inadequate. At this assessment the rating has remained 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 remained in breach of legal regulation in relation to governance at the service.

This service scored 36 (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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.The manager told us their vision for the service was to provide, “The best quality of care ensuring they are safeguarding clients and staff members.” The manager had recognised the need to improve the service and was relatively new in post.

However, prior to their appointment, there had been significant gaps in governance, including incomplete care plans, inconsistent safeguarding records, and a lack of robust assessments. These issues continued to impact the service at the time of inspection. Systems and processes were not clearly established or consistently operated, and there was limited transparency to demonstrate how risks were identified, managed, and monitored.These findings indicated that the provider had not embedded a clear, consistent culture of quality and safety across the organisation.

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

The registered manager for the service was not present during our inspection, and a new manager had been appointed by the provider. The provider failed to demonstrate effective oversight of risks, performance, and the quality of care delivered. Systems and processes in place were not used effectively to ensure care was consistently well managed, resulting in gaps in service delivery.

Staff told us they felt supported and encouraged in their development, and described the manager as visible. However, feedback from people and relatives about management was mixed. While some reported that management were accessible and responsive, others described limited contact, which led to a sense of disconnection and reduced confidence in leadership oversight.

People did not always feel they could speak up and that their voice would be heard. As reported on under listening to and responding to people, some people told us the systems in place to share concerns and feedback were not always effective. This meant a positive culture was not always promoted to enable people to speak up about their care.However, the provider had a policy in place to support staff in raising concerns, allowing them the freedom to speak up and whistle-blow. Staff were complimentary of the manager and felt they could approach them and raise any issues they had. The policy guided staff on how to raise concerns and assured them concerns would be taken seriously and investigated appropriately.

The provider valued diversity in their workforce. However, they did not always take effective action to enable staff to work inclusively with all people who used the service. People and relatives told us some staff did not communicate effectively due to language barriers, which impacted their ability to understand people’s needs and preferences. This placed people at risk of not receiving safe and person-centred care. We reported on this at our last inspection, however no effective action had been taken to enable staff to provide consistent, inclusive care.

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.

The provider did not ensure people’s health conditions were consistently assessed, recorded, and managed. Where people had complex needs, such as neurological conditions, records lacked detail to support staff in understanding and managing associated risks. Governance processes also failed to identify insufficient detail within pressure care assessments and the absence of appropriate assessments, such as Speech and Language Therapy (SALT) input for people at risk of choking.There was a lack of oversight in relation to high-risk areas of care. For example, systems did not ensure safe management of oxygen use, including the absence of clear guidance, staff training, and fire risk assessments. Similarly, medicines management systems were ineffective, as audits failed to identify concerns such as missed or delayed administration of time-specific medicines.

The provider also failed to ensure appropriate assessments and care planning were in place for the safe use of equipment, such as bed rails, which placed people at risk of harm.Audit systems were not effective in assessing and monitoring the quality and safety of the service. Audits provided did not include sufficient review of care plans and did not identify the concerns found during inspection. This demonstrated a lack of oversight and failure to implement effective systems to identify and address risks, resulting in people being exposed to unsafe and inappropriate care.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.Systems remained ineffective in supporting consistent partnership working. Care records did not routinely include details of other professionals involved in people’s care or provide clear contact information for staff to escalate concerns.This meant staff were not fully supported to work collaboratively with external partners, limiting effective coordination of care and demonstrating insufficient oversight of partnership arrangements.However, the provider demonstrated some engagement with external partners. The Local Authority Quality Monitoring Team confirmed the manager participated in regular supportive meetings aimed at improving the quality of care.

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, effective practice and research.There had been limited progress since the previous assessment, with repeated concerns identified, indicating that learning had not been embedded into practice. This meant people remained at risk of receiving poor care.Quality assurance processes were not effective in identifying risks or areas requiring improvement. There was no consistent approach to analysing safeguarding incidents or complaints to inform learning, resulting in missed opportunities to improve the quality and safety of the service.The lack of effective oversight and governance systems meant the provider was unable to drive continuous improvement or ensure lessons were learned, limiting the ability to improve outcomes for people.