Tigheaven Ltd

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 inadequate. 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.

We found the provider to be in breach of 1 legal regulation in relation to good governance.

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 registered manager and staff worked collaboratively with relevant healthcare services to ensure delivery of care.

A clear management structure was in place. Staff had clear roles and responsibilities and were informed of their roles and reporting arrangements. Staff spoke positively about the management of the service.

However the provider failed to operate a culture whereby risks to people were managed safely and staff were competent in all aspects of people’s needs.

The service operated in an open way and the registered manager was visible at all levels and available for people, relatives and staff when needed. A person told us, “The manager keeps in frequent contact. She is marvellous, she phones to check and she offered support as extra if needed.” Relatives told us, “The manager is really easy to talk to and has given me lots of advice about care and about dementia” and “The manager is very helpful with any questions or concerns we have raised. She is responsive to all issues.”

Staff also spoke positively about the registered manager. Staff told us, “The manager is good and supportive and humble,” “She is good manager, I can call her anytime or on any day” and “The manager is great, helpful and always available.”

Despite the positive feedback, aspects of the service were not well led due to the lack of systems and oversight which failed to ensure people received care from competent staff at all times and clear person centred records were in place.

Staff told us they knew how to speak up if they had concerns or something went wrong. They felt the registered manager supported them and listened to them. Staff were able to discuss issues at supervision meetings and team meetings. A staff member told us, “I am happy that the manager would take forward and resolve any concerns.”

People and relatives were able to approach staff and the registered manager if they had any concerns. A person told us, “The carers chat to me, [registered manager] keeps in touch informally and I can ask anything I might need; it works very well.” A relative told us, “If I need them (office) I phone and they pass on the information – it is very easy to communicate with them. They do have a number as well that we can get them on anytime.”

The registered manager and staff worked together as a team. Policies were in place for workforce equality, diversity and inclusion. However, there was a lack of information in place for staff and people which showed if they had any protected characteristics and the support they may need to ensure there was no discrimination and human rights requirements were adhered to. Therefore, we could not be assured that staff were supported and confident to shape services and create a more equitable and inclusive organisation.

Effective systems and processes were not in place to assess, monitor and improve the quality and safety of the services being provided to people. The registered manager told us checks were completed when visiting people’s homes, however there were no audits in place to check and monitor all aspects of the service, identify areas of improvement and address shortfalls.

We found due to the lack of clear and effective governance systems in place, improvement was needed in various aspects of the service. Improvement was needed in relation to assessing risk, staff deployment and training, recruitment checks, medicines and consent to care. Systems were not in place to respond to and manage incidents, safeguarding and complaints effectively.

There was mixed feedback received from people and relatives about the service in general which demonstrated inconsistencies with the quality of care people were receiving. Some people told us staff were kind and caring, however people’s and relatives feedback included concerns in relation to staff competence and training, inconsistencies with communication and quality of care provided by staff.

There was a lack of measures in place to obtain feedback from people and relatives. Records showed some feedback was obtained when the registered manager undertook monitoring visits. However, there were no care review meetings in place and no surveys had been conducted.

There was a lack of robust arrangements to adhere to the confidentiality of people’s records. During the onsite assessment, the registered manager was unable to provide us with all the records. The registered manager told us records were kept at people’s homes which meant records were not always being maintained securely.

We spoke to the registered manager about the issues found during the assessment. The registered manager told us they would address the issues and ensure systems were in place to manage the service effectively.

People were supported to access health and social care professionals and community organisations as and when they needed them. The service worked in partnership with relevant services when required. A healthcare professional told ,“I have worked closely with Tigheaven Ltd in supporting a client with complex needs. The care provider actively participated in a multidisciplinary network meeting involving social services, a psychologist, and a Speech and Language Therapist. The provider demonstrated openness and a willingness to collaborate with all professionals involved. There was a notable reduction in the person’s distress, and the staff team reported increased engagement and understanding from the person.”

However, records of people’s needs were not in place to ensure people received the appropriate support in accordance with their needs when accessing healthcare services.

There were no effective systems and processes in place to support learning and improvement. Audits were not in place to monitor the quality of the service and identify lessons learnt to help continually improve the service and embed best practices.