IMPACT

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• 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

Our rating for this key question remains requires improvement. The provider’s governance and quality assurance systems and processes had not enabled them to maintain effectiveness oversight of performance and any risks to the quality of people’s care. Audits and checks had not resulted in any identified areas for improvement or actions. Staff spoke positively about the management team, who they found approachable, helpful and supportive. They felt able to speak up about any concerns, and felt their voices were heard. Staff confirmed they were treated fairly and faced no form of discrimination.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff spoke positively about the service’s overall purpose and culture. They found their work rewarding and appreciated the sense of teamwork between staff and management. One staff member told us, “We work with very good people and we work for so long together. We have good carers.”

Through their regular communication with, and support of, staff, the management team had succeeded in creating a shared sense of purpose within the service. However, there was limited evidence the culture of the organisation was focused on learning and improvement. This included a lack of evidence of any reporting of safeguarding concerns, accidents, incidents or near-misses. In addition, although audits and checks took place on people’s care, these had not resulted in the identification of any areas for improvement in the service.

Staff spoke positively about the management team who they found approachable, helpful and responsive. They had confidence in the ability and willingness of management to act on any issues or concerns brought to their attention. One staff member told us, “Honestly, the manager is really good.” Another staff member said, “Yes, I can talk to them [management] about any concerns.” However, the management team did not demonstrate clear insight into issues affecting the quality of the service. Their approach to improvement appeared reactive. For example, the nominated individual told us, “No I don't think we need any improvements. You are inspecting us and will tell us what we need to improve.”

Although the provider had processes in place designed to enable them to manage risks to people, these were not sufficiently effective. Staff had not always been provided with accurate, up-to-date and complete information and guidance on how to manage known risks. Whilst the management team completed audits and checks on the service, these had not resulted in the identification of any issues, concerns or priorities for the quality of the service.

Staff felt the management team were approachable and felt their voices were heard. They confirmed they would speak to the management team about any concerns they had about people’s care, and had confidence these would be acted on. However, most staff we spoke with lacked understanding of whistleblowing as the action to take to report wrongdoing at work.

The management team had succeeded in creating a culture where staff felt able to raise any concerns about people’s care. However, staff did not demonstrate a clear understanding of the role of whistleblowing or their safeguarding responsibilities. In addition, we were unable to assess the effectiveness of the provider’s processes for investigating concerns and ensuring lessons were shared and acted on, due to a lack of recording of any such concerns.

Staff did not raise any concerns regarding their treatment by management or the promotion of equality and equity within the service. One staff member spoke about how the management team took into account their family circumstances and adjusted their work hours accordingly. Staff felt involved in the service and that their voices were heard by management. One staff member said, “I feel that they [management] listen to me.” The registered manager explained how they would seek to match staff to people’s requirements, such as gender preferences and people’s first language.

The provider had established a culture within the service where staff felt they were treated fairly and had equality of experience. Through their communication with staff, including one-to-one and group supervisions, they had found ways to engage with and involve staff, so they felt empowered to raise any concerns. Staff received training in equality and diversity to raise their awareness of these principles. The registered manager described to us how they took steps to ensure staff understood people’s care plans, by talking them through these, where English was not their first language.

The registered manager acknowledged the need for general improvement in record-keeping and auditing processes. Aside from this, neither the registered manager nor the nominated individual referenced the need for any improvements in the service, or demonstrated a clear understanding of any risks to the quality of the service. Our conversations with staff and management did not raise any concerns regarding the clarity of roles, responsibilities and accountability.

The management team conducted a number of audits and checks designed to enable them to assess, monitor and improve the quality of the service. These included audits of people’s care plans and risk assessments; analysis of feedback from people, their relatives and staff; spot checks on staff punctuality; staff recruitment checks; and observations on various aspects of staff working practices. However, the provider’s quality assurance systems and processes were still not sufficiently effective. None of these audits and checks had enabled the management team to identify any issues, concerns or areas for improvement, including the shortfalls we identified during our assessment. In addition, a number of the audits and checks completed did not include detail of what specifically was checked or observed. For example, the provider’s audit of people’s care plans included very limited information beyond the number of people’s care plans looked at. The provider had policies and procedures in place designed to protect the confidentiality of people’s personal information and gave people information about their rights in relation to the handling of this.

People and their relatives did not raise any concerns in relation to how staff and management worked, or shared information with, external agencies, teams and professionals to ensure their needs were met.

Staff did not raise any concerns regarding their collaboration with external stakeholders and agencies to support people’s care. The management team spoke about some of the health and social care professionals they had communication with.

We did not speak with any external health and social care professionals as part of this assessment.

People’s care records provided very limited insight into how staff collaborated and worked with relevant external agencies, teams and professionals to promote joined-up care.

The management team did not demonstrate a good understanding of how to make improvements in the service happen. Aside from reference to the need for general improvements to auditing and record-keeping, they did not highlight any specific areas for improvement to people’s care. Staff felt able to speak up to share any concerns they had about people’s care and had trust in management.

People, their relatives and staff were encouraged to give feedback on the service by completing a periodic feedback survey. The provider collated and analysed the feedback received. However, the provider’s quality assurance systems and processes had not enabled them to form a clear picture of how to make improvements happen, or to identify and address the shortfalls in quality and safety we found at this assessment and our previous inspection. In addition, there was a lack of evidence of learning when things went wrong, as there was no record of any concerns, accidents, incidents or near-misses having been reported by staff or identified by management.