Niche Care Wakefield

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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

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. At our last inspection this key question was rated requires improvement. At this assessment the rating remains requires improvement. We looked at 1 quality statement. There was a low level of accidents reported and we were not assured all events were reported. Audits had had not identified the shortfalls in care plans and risk assessments. We identified a breach of regulation in relation to good governance. Other audits of daily notes and medication records were being carried out. Staff felt well supported by leaders who could be approached at any time.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Although staff and the manager could describe the quality assurance processes, we found these were not always followed. Following our inspection, the provider sent us 2 updated care plans and risk assessments which showed appropriate action had been taken in response to our feedback.

We found there had not been insufficient action in respect of the breach of regulation 17 found at the last inspection. At that time, we found shortfalls in steps taken to reduce risks to people and quality checks needed to be embedded. Whilst some quality checks were taking place in the service, these had not identified the care plans and risk assessments required further detil adding. Satisfaction surveys had not been analysed and responded to, particularly where feedback was not positive. This meant learning opportunities had been missed. There was a low level of accidents reported and we were not assured all events were reported. There was no overview in place although a numerical summary was sent to the quality team each month. This was a breach of regulation 17 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. The overview of complaints from 2023 showed there was a clear log in place and overview of individual complaints, including low level concerns as well as complaints. There was evidence of management analysis and lessons learned and action taken.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.