Pleasant Valley Care Shropshire Branch

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. 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 the governance of the service.

This service scored 57 (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 clear shared vision in respect to the care they wanted to deliver but this was not always effectively embedded and was not always based on transparency. They did not always understand the challenges and the needs of people and their communities in respect to how they staffed the service.

Although the provider promoted a culture of person‑centred care, they did not demonstrate openness and transparency at the start of the inspection when they failed to disclose the number of people receiving a regulated activity, despite being directly asked. This information was later identified through records. This impacted on the overall effectiveness of leadership within the service. The provider acknowledged this failing and offered an explanation relating to time pressures and personal circumstances, apologising and recognising the information should have been shared. Whilst this initially undermined an open and honest culture, the provider was open and cooperative during subsequent site visits and showed increased transparency and engagement.

Systems to promote shared values and positive culture were not fully embedded particularly given the challenges of managing a dispersed workforce and the lack of direct oversight. However, the registered manager was passionate about their vision and tried to disseminate this informally to staff. The registered manager told us, “I have never had the attitude that Pleasant Valley Care is a business, I see it as our vocation and our life work.” Staff were clear the registered manager’s vision was to deliver a service based on person centred care which met people’s needs in the way they wanted, although this could not always be delivered effectively due to staffing pressures.

Whilst the registered manager knew how they wanted to improve the service and had an action plan in place; improvements were not always driven in a timely way to demonstrate a consistent shared direction.

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 demonstrated a compassionate approach and expressed a focus on delivering high-quality, person-centred care. Feedback from people using the service and their relatives indicated staff were kind and patient in their approach, reflecting the manager’s values. However, this positive feedback was not consistently supported by effective systems to oversee care delivery. Over the previous year, oversight arrangements had not always been fully implemented, which meant the provider could not be assured care was consistently delivered to a high standard. The provider acknowledged these shortfalls and had begun to take steps to address them, including the development of an action plan for improvement.

Staff working in the community had limited face-to-face contact with the registered manager. Supervision and team meetings were not carried out consistently, which reduced opportunities for staff to receive structured support and guidance. While the registered manager remained accessible via telephone and email, and staff felt they could seek advice when needed, this did not fully mitigate the lack of regular formal engagement. The registered manager showed a clear commitment to promoting people’s independence and dignity, but this was not always supported by robust management oversight.

The registered manager had the relevant experience to manage the service and understood the challenges of providing domiciliary care. However, this understanding was not consistently translated into practice. Systems to ensure staff were safely recruited and appropriately trained were not always effectively applied. Although the registered manager was open with people and their relatives, they were not always fully transparent during the assessment process, particularly in relation to the people supported and staffing arrangements.

Training was not sufficiently prioritised, and systems to monitor quality and performance were not consistently effective. As a result, there was a risk concerns were not always identified in a timely way, and appropriate action was not always taken to address issues and drive improvement.

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

The registered manager promoted a positive culture where staff could speak up. Staff felt confident in sharing any concerns with the registered manager and they were confident they would be addressed appropriately. The registered manager was approachable and responsive, taking appropriate action when concerns were raised and feeding back to staff where needed.

The provider had a whistleblowing policy in place and speaking up was valued as a way in which to promote high quality care.

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 provider had a thorough Equality, Diversity and Human Rights policy in place which considered staff already employed and the recruitment process.

The provider was flexible with staff working arrangements to ensure their individual needs were met. Where staff had childcare responsibilities or were studying, the provider ensured their shifts were allocated around these commitments.

The provider gave examples of where they had supported staff who were pregnant and those with religious needs when they had a bigger workforce. For example, they told us where they had adapted a staff member’s role to office based when they found out they were pregnant and also where they had adapted staff shifts around religious festivals. The registered manager told us they would continue to do this as the workforce grew and became more diverse.

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.

Although some quality assurance activity was evident, such as checks of people’s medicines, these were not consistently recorded or effectively embedded. There were significant failings in governance systems relating to staff recruitment records and training oversight. The provider recognised these failings and had started to develop systems to improve the monitoring and recording of recruitment and training; however, these were not yet fully established or effective at the time of inspection.

Audit checks in place were informal and not recorded so the registered manager could not be assured they were identifying patterns and addressing any concerns that may have arisen. Where quality assurance did take place, this lacked impartiality as the registered manager checked quality, but it was the registered manager and their relatives who delivered a large proportion of care themselves which may have placed people at risk of receiving unsafe care.

Training records showed not all staff had completed mandatory training or kept this up to date. Systems to monitor and address training compliance were not effective, which meant leaders could not be assured staff had the necessary skills and knowledge to deliver safe care.

Recruitment processes were not robust. Required pre-employment checks, including references and other safer recruitment practices, had not always been completed. This placed people at potential risk, as the provider could not fully demonstrate staff were suitable for their roles.

Risks associated with the delivery of domiciliary care were not always effectively managed. In particular, the lack of up-to-date training and incomplete recruitment checks increased the risk of unsafe or inappropriate care.

Workforce planning systems were not sufficiently robust. Staffing levels were not always sufficient which meant leaders could not effectively ensure continuity of care or respond proactively to changes in demand.

During the assessment process, the provider was not initially open and transparent in relation to the number of people receiving care and the staffing arrangements in place. This lack of transparency impacted our ability to assess the safety and effectiveness of the service and raised concerns regarding the overall governance of the service.

While the provider acknowledged the concerns identified and was committed to making improvements, a structured and effective approach to continuous improvement was not fully embedded. Action plans had been developed to address some of the identified shortfalls; however, these were in the early stages, and improvements had not yet been consistently implemented or sustained.

The registered manager was aware of when to submit statutory notifications to CQC. Where one person’s documentation had been completed in full, they had also undertaken additional analysis to identify how the care the person received evidenced compliance with each CQC key question. The registered manager told us they intended to do this for each person they supported but this was not currently consistent.

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.

The provider worked effectively in partnership with other organisations and community services to support people to achieve positive outcomes and maintain their independence at home. The registered manager recognised the importance of collaborative working and staff worked alongside other professionals to ensure people received the care they needed. People and relatives gave examples of where the provider had collaborated with health professionals and community services to meet their needs.

The provider was flexible with people’s care to enable them to engage in local community activities. The provider accessed local community groups and shared information around staff recruitment and the service they provided.

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 service had systems in place to support learning and improvement; however, these were not consistently effective. In particular, the provider had not ensured staff training was kept up to date, which limited the service’s ability to demonstrate a strong learning culture and continuous improvement in practice.

Mandatory training was not always completed or kept up to date, and some training had not been completed at all. This meant staff may not have had the most current knowledge and skills required to deliver safe and effective care and demonstrated the service’s approach to staff development and learning was not fully effective. Whilst staff felt competent and were happy with the informal learning and support received and people did not raise concerns around staff training; there was no consistent system in place to ensure all staff were equally competent and confident in their roles.

Audits and monitoring processes were insufficient to ensure gaps in staff training were identified and timely action was taken to address this. As a result, improvements in staff competence and service delivery were not always achieved.

Incidents and complaints were not always recorded so the provider could not be assured learning from these events was consistently embedded into practice. While action was taken in response to issues identified, this was not always effectively monitored or followed through.

The provider acknowledged they needed to improve the service and had begun to identify areas for development. However, systems to support continuous improvement were not sufficiently robust or consistently applied.