Initial Care Services South East Limited

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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 a breach of legal regulations in relation to good governance. There were no governance structures in place in the service. There was no assurance the processes of management oversight and quality monitoring were in place to enable the provider to identify and address any improvement needs and risks to people in a timely way. This placed people at risk of receiving poor care and avoidable harm. There was no action plan for the service and recommendations from an external audit were not implemented. There were no processes in place to ensure continuous learning and improvement. Therefore, opportunities to improve the service and learn lessons could be missed and shortfalls identified in this assessment were not recognised or actioned by the provider. The provider did not have a robust system of communicating with partners including the local authority, healthcare professionals involved in people’s care or other support providers. Not all changes in people’s needs or concerns raised by them were appropriately shared with other partners and addressed. Staff told us they felt supported by the registered manager and the service respected equality and diversity of its staff team.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The culture of the service was not always effectively supporting delivery of good quality specialist care the service was registered to provide. There was a lack of strong structure for monitoring of quality and safety. Learning and improvement was not routinely undertaken. This meant opportunities to improve the service were missed, for example, around safeguarding people. The provider was not aware of specialist guidance relevant to their type of service, so the culture of the service did not always effectively focus on protecting people’s rights.

Although the registered manager could explain what vision they had for the service and what values they expected staff to show when supporting people, there was very limited assurance on how this was monitored and discussed with staff. In practice, the culture of the service was not always supporting staff and management to adequately recognise shortfalls in the service. For example, around mental capacity, choice or how to support people when they raised concerns.

The registered manager was the only person responsible for overseeing the service. The registered manager maintained ongoing communication with staff supporting people in the community, but did not ensure that risks were well managed, people’s rights were always at the forefront of the care provided and that people’s concerns were appropriately investigated at all times. The registered manager lacked understanding of improvement priorities for the service and although staff told us they were approachable, they failed to adequately support staff in their roles and to effectively monitor their practice.

The service was not always effectively led. The registered manager did not ensure the service developed and used an effective governance system, were not aware of specialist guidance for services supporting people with a learning disability and autistic people and failed to identify shortfalls in the service, for example around risk assessments or managing safeguarding complaints. This meant risks in the service were not understood or managed well, which led to a risk of poor care.

The culture of the service did not support freedom to speak up. The registered manager was not always fully aware that feedback from staff at times constituted safeguarding concerns and failed to action all concerns appropriately and timely. This posed risk to people not being heard, concerns not being always appropriately recognised and investigated with lessons being learnt and acted on to protect people.

The provider did not always adhere to their whistleblowing and safeguarding policies. For example, when staff raised concerns from a person with the registered manager, no action was taken at the time to report, investigate the concern and to act on it to ensure this person’s safety and wellbeing.

Staff told us the registered manager respected their equality and diversity and supported them when needed, for example to be able to follow their culture and religion. One staff member said, “The agency is treating everyone equally, they’re really good.”

The registered manager ensured they treated staff in a supportive and respectful way, valuing their diversity and supporting them to have equal opportunities.

Governance systems and processes in the service were inadequate. The registered manager could not provide clear outline of their governance processes and how they used them to monitor quality and safety of the care provided.

There was no governance structure in place in the service. The registered manager showed us templates of various audits and checks but there was no evidence these were completed in 2024 apart from 1 spot check of practice for staff and a service audit commissioned with an external consultant. The improvement actions advised in this audit had not been completed, for example, around regular auditing of the daily care notes. There was no action plan for the service and shortfalls we identified around risk management, safeguarding, staff competency checks and practice monitoring, mental capacity assessments or governance itself were not identified by the provider. There was no assurance the processes of management oversight and governance were in place to enable the provider to identify and address any improvement needs and risks to people in a timely way which put people at risk of receiving poor care and avoidable harm. This was a breach of regulations in relation to good governance.

While people and their relatives we spoke to expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. The provider did not work effectively or collaboratively with key partners to ensure people received safe and joined up care. This meant important information about people's health and treatment was not shared with professionals to ensure better outcomes.

The registered manager told us they did not always update the local authority where people’s needs changed. Although they rectified this during the assessment, there was limited assurance on how effectively the provider communicated with social services to ensure all people were protected and received the care they needed. However, they communicated well with people’s families and representatives when planning and reviewing people’s care.

Partners told us there were some inconsistencies in the information about the care the service provided to people in the community they held and what the service confirmed they were providing. This could put people at risk of not receiving care as they were assessed to receive by social services.

The provider did not have a robust system of communicating with partners other than people’s relatives, including the local authority, healthcare professionals involved in people’s care or other support providers. For example, not all changes in people’s needs or concerns raised by them were appropriately shared with other partners and addressed.

The registered manager could not identify improvement needed relevant to the service at the time of the assessment or how they were monitoring these were being completed in a timely and effective way. They told us they were aware of some recommendations from the external audit in May 2024 but had not actioned these by the time of the assessment in September 2024. The registered manager gave some examples of actions they took to improve the service based on individual people’s experiences and feedback, for example, around recruiting staff who could meet people’s specific communication needs.

There were no processes in place to ensure continuous learning and improvement. As there was no structured approach to governance, there was also no action plan or other tools used to ensure improvement needs were identified, shared within the team and actioned in a timely way. Hence, opportunities to improve the service and learn lessons could were missed and shortfalls identified in this assessment were not recognised or actioned.