Bespoke Care & Support Services

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 management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The provider was in breach of the legal regulation in relation to governance at the service.

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

People reported receiving a survey but could not access it on their phones to provide feedback.

No evidence was provided to show how feedback was gathered or used to drive service improvements.

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.

The registered manager told us there had been recent changes within the service, including the introduction of an operations manager to oversee the day-to-day running. The registered manager had been less visible in recent months and had delegated key tasks to other staff without ensuring they had the skills, knowledge or support to carry these out effectively. As a result, there was limited oversight of important areas such as auditing, scheduling, and care planning, which contributed to ongoing shortfalls in the service.

People and their relatives shared mixed views about leadership. Although they said they knew who the registered manager was, they referred to different individuals, indicating a lack of clarity

about who was leading the service. Despite this, they were positive about the wider management team and described them as approachable.

Staff told us they felt supported and valued by the management team, understood their roles and responsibilities, and could request support when needed. However, gaps in oversight meant staff did not always receive the level of direction required to ensure the service was managed consistently and safely.

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

Staff told us that they knew how to access the whistleblowing policy and felt comfortable about speaking up, if necessary.

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 service employed staff from diverse backgrounds, some of which were on sponsorship licences. We received no negative feedback around equality, diversity and inclusion.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance systems were in place in the service, however we found not all expected areas of care records had the appropriate quality checks in place to ensure these were accurate and to a consistently good standard. For example, audits were not in place to review the quality, safety and accuracy of all care plans or medication, on a regular basis. We found care plans varied in quality, but daily tasks staff followed, provided detailed directions to support them to carry out care. Risk assessments were missing in areas such as continence care, choking, falls and moving and handling, and this had not been identified by the services internal governance systems. The Commission had not received statutory notifications for safeguarding incidents. The providers high level audits gave an overview of care standards within the service, but these had been ineffective in addressing the concerns raised during the inspection. The registered manager took feedback on board from the inspection and advised they would include it in their ongoing improvement plan.

The provider understood their duty to collaborate and work in partnership, so services worked for people. They shared information and learning with partners and collaborated for improvement. The registered manager and staff demonstrated they understood the importance of working collaboratively with other professionals, were receptive to feedback, and welcomed suggestions for development.

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.

Even though shortfalls were found during the inspection, the registered manager was accepting of the feedback provided and took this onboard to learn and improve. They told us an improvement plan would be in place promptly to help address the concerns raised and provide assurance.