Sentricare Birmingham

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 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 good governance. Not enough improvements were found at this assessment, and the provider remained in breach of this regulation.

The provider was previously in breach of the legal regulation in relation to good governance. Not enough Improvements were found at this assessment, and the provider remained in breach of this regulation.

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 had a shared vision, strategy and culture grounded in transparency, equity, equality, human rights, diversity and inclusion. This approach emphasised meaningful engagement and a strong understanding of the challenges faced by people and their communities.

Staff feedback indicated that they received strong managerial support and felt confident in the guidance provided, reflecting a generally positive internal culture. Staff described good support from the registered manager, senior staff and the office team. This suggested a culture where staff felt comfortable seeking help when needed.

Staff felt there was a culture of collaboration and felt listened to. They reported a strong sense of teamwork and mutual respect. One staff member said, “Really good colleagues and manager, office staff are good and treat us well.” Processes were in place to seek both people’s and staff feedback.

The provider demonstrated inclusive and values‑driven leadership at all levels. Leaders understood the context in which care, treatment and support were delivered, and they modelled the organisation’s culture and values in their everyday practice. They had the skills, knowledge, experience and credibility needed to lead effectively, and they did so with integrity, openness and honesty.

However, the registered manager and provider had not identified several of the concerns highlighted during this assessment. Despite this, the management team were open, transparent and responsive throughout the process.

Staff spoke very positively about the registered manager and wider management team. Leaders were described as visible, approachable and supportive, regularly leading by example. Staff provided multiple accounts of managers participating directly in care delivery and taking prompt, appropriate action when issues arose.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were aware of the term ‘freedom to speak up’ and told us the service encouraged them to do this if they had any concerns. One staff member said, “I reported a problem and the office staff asked the right questions and I was satisfied with the outcome.”

The provider had a whistleblowing policy in place, which set out how staff could raise concerns both internally and with external agencies. This helped create an environment where staff felt supported to report issues and contribute to a safe culture.

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.

The manager demonstrated how they valued staff by working closely with them to understand staff’s individual needs and by making reasonable adjustments to accommodate and support them in their work. Staff told us where adjustments were made to their working week to support them. Staff had completed equality and diversity training, which helped promote an inclusive approach and ensured they understood their responsibilities in delivering equitable care.

The provider did not always have good governance.

Governance systems were not effective. Although monthly care plan audits were completed and the service used an external quality and compliance consultant, there was limited evidence that people using the service or their relatives were meaningfully involved in review processes. One relative told us, “I don’t always feel confident issues are followed through properly.” A person told us, “I don’t feel listened to by the office staff at all.”

We raised the lack of evidence that people using the service or their relatives were meaningfully involved in reviewing and developing care plans. In response, the registered manager sent us copies of emails they had sent to people following telephone reviews as evidence of their involvement in care planning. However, these emails were from 2023 and there was no recent evidence to demonstrate ongoing involvement

The compliments tracker lacked clarity on how compliments were captured and was completed solely by management.

Furthermore, audits failed to identify extensive medicines management discrepancies across pen pictures, MAR charts, blister packs and prescription directions. This indicated a failure to detect, assess and respond to risks.

Collectively, these issues provide insufficient assurance that governance arrangements were effective in driving improvement or maintaining safe standards of care.

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.

People and their relatives told us the service worked well with health professionals to ensure people received safe care. Staff explained they made referrals to health professionals via the office team, and that advice or guidance received was shared promptly so people’s needs could be reviewed and responded to.

Care plans demonstrated involvement from external professionals, including district nurses, and outlined appropriate escalation steps when concerns were identified. Documentation also showed consultation with social workers regarding mental capacity assessments and best‑interest decision‑making processes.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider outlined the use of audits, surveys, and a quality and compliance consultant, indicating an intention to strengthen governance and improve quality. Although these systems were in place, the evidence demonstrated that governance processes were not effective in identifying and addressing key risk, particularly in relation to medicine discrepancies. Records did not show consistent implementation of improvement actions arising from audits or feedback.