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Leaf Care Services

Overall: Good read more about inspection ratings

Unit 4 - St Benedicts View, Grapes Hill, Norwich, NR2 4HH (01603) 618111

Provided and run by:
Leaf Care Services Ltd

Report from 31 July 2024 assessment

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Well-led

Requires improvement

Updated 13 November 2024

The governance system did not give complete oversight to identify informal complaints and concerns raised verbally and via feedback systems. This has led to some people and relatives feeling they had not been listened to, themes not being identified and addressed to resolve concerns. This included areas such things as care call times, ensuring all staff had the required training to meet people’s needs and identifying inconsistencies in care records. This had resulted in a breach of good governance and an action plan request. The Nominated individual (NI) and registered manager had a shared vision and strategy for the service and worked with the Commissioners to ensure it matched their needs. The management team had recently been expanded to support the registered manager, who kept themselves updated via networking and training. Providers and health care professional praised the staff and management team for the professional, efficient and caring working relationships they had developed with them to ensure people received the personalised care they required. The governance system had recently changed and the NI and registered manager made further changes to ensure the issues we identified were being addressed.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Shared direction and culture

Score: 2

The NI and registered manager were clear on the shared direction of the service and were actively engaged in strengthening and winning bids with the commissioners to secure the future of the service. The commissioners of the service felt they were an innovative provider who had worked with them to fill gaps in care provision, who were small enough to be agile but large enough to have infrastructure to take advantage of hours on offer. The service user’s handbook had details of the aims and objectives including such things as culture and values. Staff said they were made aware and involved with the vision and strategy via staff meetings and it was also in the staff handbook. Staff felt the culture was good and they felt like a group or family. However, although the NI and registered manager were proactive in some aspects, we identified gaps of oversight within their governance in a number of areas including ensuring all feedback was captured, actioned appropriately and any themes or trends identified to help shape the service.

Capable, compassionate and inclusive leaders

Score: 2

The NI and registered manager had worked at the service for a number of years and had provided consistent management. The registered manager kept themselves updated by being part of registered manager’s networks and had support from an external management consultant once a month which helped provide guidance and support. The management/office structure had recently expanded to include a medication compliance officer, human resource, training and finance managers, deputies and such roles as a wellness and mental health lead. With the changes there were some gaps in oversight of such things as staff training and capturing informal complaints which were being addressed. People and relatives were aware of who the manager, seniors and office staff were from the contact they had. A who’s who of staff had been included in the newsletter sent to people. Staff overall felt supported. They felt the management team were approachable and service was well managed. A number of staff said how friendly and flexible their contact with the management team was, especially with face-to-face communications, more than via phone/text or email due to occasional delays in responding.

Freedom to speak up

Score: 2

People and relatives told us they did not always feel listened to when they contact the office or completed feedback forms. We identified gaps in the management of informal complaints. This meant these were not reviewed to identify themes and trends as well as the issue itself not being investigated and resolved with the person and any required changes made. Staff felt if they raised a concern this would be taken seriously, and they felt supported in doing this. There were appropriate policies in place to support ‘speaking up’ such as whistleblowing and duty of candour. This topic was regularly discussed as part of supervision and a topic within newsletters.

Workforce equality, diversity and inclusion

Score: 3

Staff felt they were supported to help with their work/life balance. They gave examples where they had moved rounds, so they could work closer to home and to help with child care arrangements. There was bullying and harassment policies in place and staff said on occasions when incidents of this type had happened, they had been dealt with promptly and resolved. Where people and relatives had commented on ethnicity and raised concerns the managers had worked with them to improve relationships in this area.

Governance, management and sustainability

Score: 1

There was a governance system in place to monitor the service, however, we identified gaps which meant not all issues were being captured to give total oversight of the running of the service. This included for care records. Spot checks were carried out regularly with the person and, if appropriate, their relative to ensure the care still met their needs. There were high risk audits completed by senior staff who reviewed care received to identify changes or referrals to health care professionals when needed. However, this did not identify inconsistencies and gaps within the records, which could lead to inappropriate care being provided. The complaints and concerns procedure was not being followed for capturing informal complaints, concerns raised at spot checks and from feedback forms and addressing these at an early stage as well as identify themes and trends. The logs for safeguarding and complaints needed further developing to capture all details. There was no oversight to ensure all staff attending care calls had the required training to meet the needs of the person. The systems in place for auditing of care call times was inadequate with the electronic call system making it difficult to ascertain actual call times and to identify carers swapping care calls around to what was on rota and these being actioned consistently.

Partnerships and communities

Score: 3

The management team had built good relationships with commissioners, other providers and health care professionals. They worked with other providers to meet people’s needs, who praised the managers for their knowledge of care needs and setting up packages which were personalised and detailed. They said they found the team to be efficient, knowledgeable and caring. Health care professionals gave positive feedback about working with them collaboratively to meet people’s needs saying they were professional and organised. A new role of mental health and wellbeing champion had been created to work with people to improve their quality of life and help encourage them to access community services. They also supported staff.

Learning, improvement and innovation

Score: 2

The registered manager and NI were open to look at ways to improve and innovate. This was shown by the way they had engaged with the assessment process which had highlighted gaps within their governance system they had not identified. They also attended registered manager networks and worked with a management consultant on a monthly basis. They had developed case studies to look at what had worked well so this could be celebrated and learnt from, not just concentrate on when things had not gone so well. There had been investment in the training of staff, facilities and equipment to improve the quality of training. They had achieved NVQ accredited training status, and the registered manager was a PTLLS trained trainer. For staff they had invested in fuel cards, pool cars and a mobile app so staff were paid data allowance to help when there was poor mobile signal, with GPS tracking to help with call monitoring and staff safety.