Exclusive Care Services

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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

We found 2 breaches of the legal regulations in relation to governance and notification of incidents. Processes in place as well as the ethos, values, and behaviours of leaders and care staff did not ensure people using services led confident, inclusive and empowered lives. Governance processes were not effective and did not hold staff to account or keep people safe. There was a poor culture within the service. Leaders at the service failed to lead by example, the provider and registered manager were not always open and transparent. The provider and registered manager had failed to share information about incidents with the appropriate bodies. Statutory notifications had not been sent to CQC as required.

This service scored 21 (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 provider had failed to address concerns and ensure people and their loved ones were involved in the service in a meaningful way. There were no robust systems in place to monitor the quality of the service or ensure people were valued or respected. The culture of the service was poor. Not all staff had a well-developed understanding of equality, diversity and human rights. Staff lacked understanding around the importance of delivering safe, high-quality, compassionate care. Some people told us they did not always receive care that was compassionate or high quality and respected their human rights. For example, some people fed back staff were rough with them during personal care and some people felt staff had not maintained their dignity.

The provider and registered manager had not ensured robust systems and processes were in place to ensure people received safe care and treatment. Staff did not receive adequate supervision or oversight to ensure their practice and delivery of care and support ensured people were safe. There were poor systems and oversight of how incidents were reported and managed and staff had not received the appropriate guidance or training to ensure an open culture of reporting and learning lessons was embedded in the service. The registered manager and provider had not considered how they would safely and effectively monitor the quality of the service as more care packages were taken on. When complaints and concerns were raised by people and relatives the provider did not review information effectively to identify repeated patterns which meant mistakes were repeated and people exposed to further harm.

The registered manager, provider and senior staff lacked the knowledge and skills to ensure people received safe care and treatment. The registered manager and provider failed to act on concerns raised by people and their loved ones. Staff gave mixed feedback about leaders at the service. Some staff told us roles and responsibilities were not clear and therefore actions were not always taken in a timely manner. The registered manager told us after the assessment they were reviewing the roles of staff to ensure that roles and accountabilities were clearly defined. Some staff told us the leadership at the service was good, and that they received the support they needed.

Leaders at the service including the registered manager, provider and service manager failed to lead by example, and ensure risks were well managed. There were significant shortfalls relating to incident investigation, and risk mitigation which were not addressed by the management team. Concerns we raised to the management team were not known or identified through their processes and systems. Staff who had no previous experience in healthcare or complaints management sometimes oversaw disciplinary issues. Leaders at the service did not always demonstrate they were capable. A relative complained that leaders at the service had not addressed their concerns and had not accommodated what was agreed during their loved one’s assessment. Another relative shared leaders lacked compassion, as their loved one was left without care, or tried to complete their personal care themselves as staff were often too late to support them. There was a poor culture within the service, which increased the risk of people being harmed. Staff and leaders were not always open and transparent.

The registered manager and provider had not ensured there was a culture of speaking up where staff consistently and actively raised concerns without fear of detriment. When concerns were raised leaders did not always act upon them or share lessons learned. Staff did not always feel able to raise concerns internally. CQC received a number of concerns from staff relating to their treatment. One staff member shared, “Very disappointed as they do not respect care staff, do not want to listen to us and talk very rudely.” Staff we spoke with did not always understand who outside of the service they could contact to raise concerns, for example the local authority safeguarding team, or CQC.

Systems to ensure people received an apology when things went wrong were ineffective. We identified numerous incidents where people had complained or been involved in incidents and an investigation, outcome and apology was not provided by the registered manager or provider. There was a closed culture within the service which impacted on people's outcomes. A closed culture is a poor culture in health and social care services that increases the risk of harm to people. For example, there was a lack of openness and transparency from staff and leaders regarding incidents and accidents. The registered manager and provider failed to ensure there were robust processes to support staff to share their concerns internally or externally. For example, staff had not followed the whistleblowing process in relation to concerns about a person being restrained.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager told us they completed checks on the quality of the service, but these were not formalised or written down. The registered manager told us they had oversight of the service, however they failed to identify the significant and widespread concerns identified within this assessment. Staff were unable to tell us any lessons learnt or improvements implemented as a result of any incidents that occurred. The registered manager and provider told us that not all notifiable incidents had been reported to the CQC as required. The registered manager and provider agreed there was not an effective system in place to manage the performance of staff.

Systems to ensure compliance with legislation and the providers internal governance were poor. There was a lack of oversight of the service. The registered manager and provider did not complete any formal checks on the service to identify where improvements were needed. Office staff including care coordinators completed some checks for example, they reviewed documentation missing from care plans. This evidenced that a lot of documentation was not fully completed, including mental capacity assessments and guidance for staff. The registered manager told us they reviewed this information but there was no evidence they had taken any action or addressed any of the missing information. We identified 11 incidents that should have been reported to the CQC, which the registered manager and provider had failed to do. The registered manager and provider failed to follow their own policy in relation to disciplinary processes. We identified 1 staff member had been served 3 final warnings within 4 months, and a further extended warning the following year following 4 significant safeguarding issues. The registered manager and provider could not evidence what action they had taken to mitigate risks to people. No risk assessment had been put in place, and they could not provide any evidence they re trained the staff member prior to them supporting people once more. The providers documentation evidenced that a large number of staff had on-going disciplinaries at the time of our assessment.

While some people and relatives we spoke to expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. Some people felt the staff did not communicate well with other professionals, for example, 1 person described an issue which the provider had failed to escalate to social services to rectify, after numerous times of asking the provider.

The registered manager told us when incidents occurred, they did not always inform the relevant agencies. The registered manager told us they attended forums and groups to learn and share best practice, however there was no evidence any improvements had been implemented. Care staff did not always share information with office staff relating to people’s health concerns. For example, care staff had failed to report to office staff that 1 person had refused support with their personal care for 4 days. Care staff had not identified the person was at risk of self-neglect and may need other healthcare professional intervention. When office staff were made aware of health concerns, steps were taken to share concerns with relevant healthcare professions. For example, when a person needed support from the community nurses for their catheter care.

Other health professional partners have worked alongside CQC during the assessment. Local authorities have removed a number of the care packages they fund from this provider and continue to review further care packages due to concerns over the safety and wellbeing of people. The local authorities also told us they had received mixed feedback from people and their relatives regarding the care and support they received from this provider.

The registered manager and provider were not always open and transparent with external stakeholders and agencies. We identified at least 6 incidents that had not been reported to the local authority. We identified 11 incidents that had not been reported to CQC. The registered manager confirmed incidents were not always shared with social workers.

The registered manager and provider had not allowed staff time to prioritise their professional development. Staff had not completed the training needed to carry out their role, for example 1 staff member was completing medicine competency checks, however they had not completed the medicine training. Learning from incidents were not shared with staff. Staff were unable to tell us about recent incidents of concern that had recently occurred with people they supported. The registered manager and provider could not demonstrate they used best practice, for example, in relation to medicines management or from safety alerts for example with scalding risks.

There were significant and wide spread concerns identified during this assessment. The registered manager and provider could not evidence action had been taken to learn and improve the quality of the service. There was not a consistent approach to measure outcomes and impact for people. There was no evidence that the registered manager and provider reviewed best practice. There was a lack of understanding around medicines management and oversight, and opportunities to implement improvements had been missed. For example, 1 person was identified to have 2 pain patches in situ. The registered manager and provider missed the opportunity to review practice in relation to pain patches. When things went wrong there was a lack of leadership, oversight and investigation from the registered manager and provider. Similar concerns were raised by people and their loved ones relating to; staff being rough during personal care, however action taken to address this was not clear or documented. Opportunities to develop staff practice were missed. The registered manager and provider failed to identify that senior staff did not always have up to date training to enable them to carry out their role.