Ethan Care Woking

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.

This is the first assessment for this newly registered service. This key question has been rated requires improvement.

Governance systems were not always effective in providing oversight and driving improvement. However, leaders were compassionate and committed to supporting the delivery of high-quality, person-centred care.

The service was in breach of 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 always have a clear, consistently shared vision and culture that was fully understood and embedded across the service. Leaders had defined values in providing compassionate and respectful care, following risk assessments and ensuring staff were trained to meet people’s needs.

We received mixed feedback from people and relatives regarding staff confidence and ability to consistently meet people’s needs. Whilst some people spoke positively about staff knowledge and support, others felt staff did not always demonstrate confidence. People told us, “I have found them to be good. Although, you really have to work hard with the carers.” and “[Person] is reluctant to ask for things to be done. Because of the communication difficulties, they won’t say what they need and want to the carers.” Whilst there was evidence that people’s needs were discussed and staff were aware of the service’s values, this indicated the service’s vision and values were not always effectively translated into practice when supporting people.

Staff and leaders demonstrated an understanding of the key principles of Right Support, Right Care, Right Culture through their approach to supporting people to maintain their independence, make choices and be treated with dignity and respect, although they were not familiar with the guidance by name.

The provider 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 promoted the organisation’s values and fostered a positive and inclusive culture where staff were treated with respect. Leaders responded to feedback and took action to address identified issues to ensure people received safe and effective care. Leaders actively undertook relevant qualifications and professional development opportunities to enhance their knowledge, skills and competence.

Staff described leaders as supportive. They told us, “[The registered manager] is very supportive and they are always on hand to offer support. They always want to help when we have issues in the field. They are always there to assist.” and “[The registered manager] always encourages us to do as much as we can, support the clients to be independent. Spot checks are done quarterly.”

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

Staff understood whistleblowing procedures and how to raise concerns should the need arise. One staff member told us, “[The registered manager] makes it easy for us to approach them and you can see that during team meetings. They don’t come across as the manager and they allow people to speak freely.”

Leaders completed spot checks to observe staff practice and people’s experiences of care, which provided opportunities to identify concerns and ensure care remained person centred.

Supervisions, team meetings and regular communication with leaders provided opportunities for staff to raise concerns. Evidence showed staff and leaders had regular discussions about care quality and practice.

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.

Staff told us they were treated fairly and received training and guidance to help them understand equality, diversity and inclusion. Policies and procedures were in place and staff felt confident discussing concerns with leaders.

Leaders demonstrated an awareness of inclusive practice and a commitment to fair treatment, supported by organisational policies. Leaders encouraged all staff to undertake qualifications and development opportunities, ensuring these were accessible to everyone.

The provider did not have effective systems to identify and address risks to the quality and safety or the service. Although processes were in place, there had failed to identify concerns we found during this assessment.

Audits of medicines and care plans had not identified inaccuracies within medicines records, including discrepancies between prescribed medicines, pharmacy dispensing information and care documentation. Care plans did not always contain accurate or up-to-date information to guide staff in maintaining people’s safety, such as the use of pendant alarms. This meant staff could not always rely on care records to provide consistent support.

Although staff completed checklists within electronic systems to confirm tasks had been completed, we found gaps in written daily records. Leaders told us they had discussed recording expectations with staff, however these concerns had continued. This demonstrated that actions taken had not been effective in achieving sustained improvement.

The failure to identify and address concerns through established governance processes represented a shortfall in oversight and reduced confidence in the provider's ability to recognise and respond to risks in a timely manner. Following the assessment leaders acknowledged these concerns and described ways they have improved systems to monitor quality, risk and performance after the assessment.

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

The provider worked effectively with a range of healthcare professionals to ensure people received coordinated care and support. One professional told us, “The management team regularly ask for professional advice and guidance, especially when a person's needs have changed or when they need support with decision-making.” and “They are receptive to feedback and recommendations, and I have found that they respond positively to professional challenge.”

Leaders worked in partnership with people and families to identify opportunities that you would enhance their community involvement. Additional support was arranged to help people access shopping facilities, attending appointments and participate in meaningful activities.

The provider did not always focus on continuous learning, innovation and improvement across the organisation. Systems were not always effective and had failed to identify or address the concerns found during this assessment.

Audit systems were in place and had been completed. However, these had not consistently identified omissions and gaps within care plan documentation or medicines administration records. This meant there was limited assurance that opportunities for improvement had been recognised and embedded into practice.

Staff told us they felt comfortable raising concerns. Leaders sought staff feedback through surveys to identify opportunities for improvements. Survey results were compared over time to help the provided understand whether improvements had resulted in positive outcomes for staff.

Systems were in place to review incidents, complaints and feedback. People and relatives had opportunities to provide feedback and contribute ideas for improving the service. Learning was generally shared with staff through team meetings and supervisions.