Innovative Start Ltd

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

We identified two breaches of the legal regulations. The provider and registered manager failed to ensure systems and processes were in place for records to be consistently accurate and up to date. Quality assurance processes in place were not effective and did not highlight the concerns were found. The provider and registered manager failed to act on previous feedback in a timely manner to drive improvement. The Care Quality Commission were not always routinely notified of events the provider was legally required to make us aware. We received variable feedback from staff in relation to whether they felt free to speak up with concerns. However, all staff understood their roles, responsibilities and duty to report concerns for people’s safety and wellbeing.

This service scored 11 (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.

Leaders outlined management and support structures in place which aimed to ensure staff felt able to speak up. Staff could speak with an ‘ambassador’ such as a more senior care worker who could escalate a concern, if the staff member themselves was not confident to confide in a senior leader. We noted the service’s improvement plan described in March 2024 staff had appeared ‘timid’ and ‘scared to speak’ in front of the recently departed registered manager. The nominated individual explained they were using team meetings and supervisions to encourage staff to make direct contact with any concerns. It was also stated an additional staff survey was planned to gather anonymous views of management and support arrangements. We identified factual inaccuracies and incomplete information within the service’s safeguarding and whistleblowing policies, which we have reported on further under Governance, management and sustainability. We also identified the service had failed to report some concerns to the local safeguarding authority which we have reported on under Safeguarding within this report.

All staff we spoke with confirmed they had received safeguarding training, and could identify how they would escalate a concern of poor practice via whistleblowing procedures. Most staff told us they would feel comfortable and confident raising concerns with leaders, and explained their feedback was gathered during team meetings, surveys and supervisions to drive improvement. However, during our assessment we also received feedback which indicated not all staff felt they would be protected to speak up within the organisation, and not all staff trusted leaders to act with openness and transparency. Leaders told us an open door policy was in place, however we noted during a September 2023 team meeting staff were informed they could not ‘just pop in’ without an appointment. This indicated an open door policy had not been fully established throughout the whole of the past year. A staff member also noted the open office layout could make it more difficult for someone to speak up, suggesting, “On the issue of office setup, l would suggest if [leaders] have their own office separated from others, so that there is privacy if employees would like to talk to the manager pertaining issues that are confidential”.

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 nominated individual advised it was unclear what level of auditing was conducted by the recently departed registered manager who had not met the provider’s full expectations. The nominated individual noted they had retrospectively commenced audits, explaining they had reviewed the management structure and planned to take a more active auditing role to drive improvement. Care staff understood their role and responsibilities, including their duty to report changes or concerns for people’s welfare, and the importance of protecting people’s private information. Staff told us regular team meetings provided useful feedback, with a staff member advising, “We share ideas and how we can better ourselves and how we can better deliver services to our clients”.

The provider and registered manager failed to comply with regulations and legal requirements. The provider and registered manager had not routinely ensured all events which were legally required to be notified to us were made. We spoke with the provider about their understanding of when to notify the Commission, their response was not in line with the legal requirements. We found records were not always accurate and reflected each person’s needs. We found some care plans contained contradictory information. For instance, one person’s care records had a different date of birth listed on documents. We found limited evidence of effective care plan auditing, which would have potentially identified our concerns. We found policies were not routinely effective and contained inaccuracies. The provider's accident policy cited an incorrect date of legislation. The policy stated “risk assessments should be reviewed and any learning from the investigation applied in order to prevent recurrence and maximise safety in the future.” However, we found this was not routinely the case. We found evidence of incidents which had been recorded in daily notes by care staff, however, they had not been recorded in line with the policy or investigated to prevent a reoccurrence. Records were poorly maintained; some records were inaccessible to the provider until after our site visit and it was frequently unclear when information was added or altered, and by whom. Several audit actions were marked as ‘ongoing’ with no specified target completion date or update added to indicate whether progress had been made. The issues we found meant people were potentially put at risk of harm as systems and processes were not robust and established to ensure people’s needs were assessed or monitored and to ensure risks to the quality and safety of the service were managed.

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.