Evolve Supporting Prospects

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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 identified a breach of the legal regulations. Effective governance systems to evidence clear management and oversight of the service were not in place. Audits and checks in areas such as, safe recruitment, visit logs, medication practice, staff recruitment, training and support and clear and accurate records, were not completed helping to identify and drive improvement. Formal systems to seek and act on feedback from people, staff and other stakeholders were also needed helping to evaluate and improve services. Policies and procedures had been reviewed and updated however did not accurately reflect good practice guidance or relevant legislation; nor were they followed in practice, for example; management and safe working practices, mental capacity, and staff recruitment, training, and support. This meant staff did not have procedures to effectively guide and support them in their role. Since our last inspection there had been changes in the management team. The service was currently supported by an acting manager; application to register with the Commission was to be submitted. The acting manager was currently completing training in management in health and social care. People and staff spoke positively about the management of the service. Managers were described as supportive, approachable, and fair. One staff member told us, “I have no concerns, they are doing good.” The local authority had recently carried out a quality monitoring visit. The acting manager was working to address the shortfalls identified.

This service scored 61 (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.

The acting manager told us as part of their learning and development they were currently completing a leadership course in health and social care. We were told the new nominated individual does not have a background in health and social care. They split their role between management responsibilities, proving on-call support and delivering care. The provider said they felt they too should complete the leadership course to further enhance their knowledge, as well as enable them to effectively support the acting manager. We found formal systems to support staff were not in place such as induction, supervisions and team meetings. However, staff told us they were happy in their role and felt supported by managers. Comments included, “I don’t’ have any issues of concern. It’s okay to work here. I feel genuinely looked after and valued”, “I have no complaints about the office and the management” and “Yes, it is a good place to work, I love my job. I have no concerns they are doing good.”

Over the last year there have been changes within the management team. The nominated individual, acting on behalf of the provider has changed and there is currently no registered manager. During our inspection we were assisted by the care co-ordinator who had been the acting manager for approximately 12 months. We were told it was their intention to register with the Commission. We were told regular management meetings were held between the provider, nominated individual and acting manager. However, these were not recorded to evidence effective leadership and delegated roles and responsibilities to address the needs of the service. Staff were provided with an employee’s handbook which clearly identified their roles and responsibilities and what they could expect form the provider.

Managers told us they had regular contact with staff both informally and through occasional team meetings. One staff member told us, “I am able to share my views and concerns.” Staff told us they felt able to raise any issues or concerns, including poor practice. Those staff we spoke with felt managers listened to them and were fair. Staff were aware of the agencies whistle blowing procedure. One staff member told us, “I would escalate anything if needed including whistle blowing, I am confident the manager would respond appropriately.” Staff told us other opportunities for them to share their views were not provided, such as, individual supervision sessions and feedback surveys. One staff member also said, “Currently staff meetings are minimal.”

Staff were provided with a copy of the agency handbook. This outlines the policies and procedures in place and contractual obligations. Information included guidance on what they should do if they needed to report information or concerns to management. Other processes to seek the views of staff were not formally embedded, such as feedback surveys, regular team meetings and individual supervisions. We were told there were no records to review as no issues had been raised or sought from staff.

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.

We discussed with the provider the management arrangements and delegated roles and responsibilities. The provider felt the current structure in place was appropriate for the size of the service. This comprised of the nominated individual and care co-ordinator in day to day responsibility, with the previous nominated individual (also director) visiting approximately 1 day a week. These arrangements did not reflect the management structure detailed with the service contingency plan, which included additional roles with varying responsibilities. The service currently employs 16 staff who supported approximately 60 people a week, which the provider felt was ‘manageable’. However, this was not reviewed by the management team. The acting manager told us they had been working for the service for 12 months and were planning to register with CQC. Whilst experienced in care they had no previous management experience. They told us, “I enjoy working here. It is quite busy. It is a demanding role.” Staff told us they were aware of their role and responsibilities and had access to ‘on-call’ support throughout the day should an emergency arise, or concerns needed to be raised. The provider was aware of their legal responsibility to report events which may impact on people or the service.

Robust audits and checks to clearly evidence management and oversight of the service were not carried out in areas such as; workforce planning, safe administration of prescribed medicines, accurate and complete care plans and risk assessments and robust recruitment, training, and development of staff. Without such systems we could not be assured the provider was able to identify and make improvements needed within the service. We were also told assessment of staff practice through competency assessments and spot checks were also completed. However, there was no evidence to corroborate this. Policies and procedures were not sufficiently robust. Information did not accurately guide staff in best practice or current legislation; nor were they always followed. On-call support was provided by the nominated individual (NI). The NI had recently created an electronic call log so any calls could be noted. However, we were told the use of on-call support had reduced as people had been given access to staff numbers so they could contact them directly. This meant managers would not be able to monitor calls made or received. A business improvement plan had been developed following a quality monitoring visit by the local authority commissioning team. The improvement plan explored areas such as, client satisfaction and overall quality of care; increasing efficiency; enhancing staff retention by introducing new training programs and expanding services introducing new care packages and developing partnerships with local organizations. However, this did not reflect specific shortfalls identified during the local authority review and our inspection. We were not assured effective systems were in place to support and develop managers in their role and understanding of their legal responsibilities. This meant there was a breach of regulation, Good Governance.

The provider has established a working relationship with the local authority to address areas of improvement. The provider has links with other services, for example, health care professionals and training providers to support people and staff in the delivery of care.

The local authority had informed us of their on-going work with the provider following a quality monitoring visit, which identified areas in need of improvement. Regular visits were to be made to monitor and review progress.

The provider’s business plan incorporated information from partner agencies. This was to used to help drive improvement.

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.