Community Care Advice Centre

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 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.

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 vision and strategy, but the delivery of care and lack of accurate records was not aligned with the vision and culture of the service.

The service’s strategy included to improve health and wellbeing of communities and quality of service. However, service objectives for Community Care Advice Centre were not being monitored through audits and lack of accurate records relating to risk assessments and care plans meant there was lack of oversight of the delivery of the strategy for Community Care Advice Centre.

Staff members told us the culture within the service was open and positive and they enjoyed working for the service. A staff member told us, “Culture is an open and positive culture. We all get along; we are like a family here. The manager is always approachable.”

Leaders did not always have the skills, knowledge and experience to lead effectively.

The registered manager knew people well and was committed in ensuring people received safe and effective care. This was done through seeking feedback from people and staff. Spot checks were also carried out to ensure staff delivered high quality care. A relative told us, “Management are very good and [registered manager] is very responsive. We are happy with them.”

However, there were shortfalls with risk assessments, personalised care plans and record keeping which would require addressing to ensure people always receive safe care and support.

The registered manager told us about a potential concern raised by a relative resulting in safeguarding. However, the Care Quality Commission had not been notified of this concern as part of the providers regulatory requirements.

Staff meetings for coordinators and support workers were held regularly by the management team. The agenda included discussion on supervisions, care plans, training and scheduling.

Staff were positive about the registered manager. A staff member told us, “[Registered manager] is a good manager, he is supportive and approachable.” Another staff member commented, “[Registered manager] is such as nice guy. I like working for him. He always has time to help you. He is supportive.”

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

A whistleblowing policy was in place that included details on how to raise concerns both internally and externally, which allowed staff freedom to speak up. Whistleblowing is the act of reporting wrongdoing, misconduct, or illegal activities within an organisation.

Systems were in place for staff to raise concerns internally and externally. Staff knew how to use the whistleblowing policy and understood their role and responsibilities of reporting concerns and knew who to go to if they needed to, for example, contacting the local authority with their concerns.

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 did not have any concerns with lack of support and were positive about the service and the management team valuing diversity.

Minutes from staff meetings demonstrated that staff were fully informed about service developments and staff were able to provide feedback at these meetings. The provider encouraged an open-door policy, allowing staff to raise concerns or suggestions comfortably.

The provider had a clear equality, diversity, and human rights policy to ensure that neither staff nor people using the service were subjected to discrimination. A staff member told us, “There is always inclusion irrespective of where we come from. Its good working culture.”

The provider did not have clear responsibilities, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

There was not an effective quality assurance system in place to identify shortfalls and act on them to ensure people were safe.

The registered manager told us that audits were carried out on review of care from health professionals but this was not recorded to ensure shortfalls could be identified and prompt action taken when needed. This meant there was not a robust system in place for audits such as on care plans, recording consent and risk assessments to ensure people received safe and personalised care and there was oversight on care delivery.

There was a lack of oversight on staff calls as we found there were some late calls and staff not staying the duration of the calls. Although the registered manager told us this was due to people becoming more independent and requiring less staff support, there was no records kept to show the change in circumstances.

The lack of robust quality assurance processes and not keeping an accurate, complete and contemporaneous record of people who used the service, may impact on people’s care and support if staff are not able to support people safely and meet their needs.

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

The registered manager and staff told us they worked in partnership with health and social professionals to ensure people were always in the best of health. Records confirmed people had access to social and health professionals to ensure they were in the best of health such as physiotherapists.

The provider did not always focus on continuous learning and improvement across the service.

Robust systems were not in place for continuous learning and improvement. Effective quality assurance systems were not in place to ensure there was oversight on care and support as we found shortfalls with care plans and risk assessments. Lack of quality assurance systems meant that it would be difficult to identify and act on shortfalls to ensure there was a culture of continuous improvement.

Quality monitoring systems were in place that included feedback from people and staff.