Deep Heart Care Wiltshire

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

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this service since it registered on 6 October 2023. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The provider was in breach of legal regulation in relation to the governance of the service and failing to notify CQC.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The provider used an electronic care planning and medicines system. Staff had faced significant network issues with this system in certain areas. The provider did not have an adequate business continuity plan for how they were going to manage this disruption to their service. Staff were provided with information about the provider values during their induction. However, when we spoke with staff about this, they did not demonstrate knowledge of the values or that they understood what it meant for their day-to-day work. The registered manager carried out unannounced spot checks on staff to check how staff were working in people’s homes.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. Leaders were not aware of relevant legislation for the service and nationally recognised good practice. During discussions with the leaders about governance it was clear they were not aware of all regulatory requirements. For example, the registered manager was not aware they needed to notify CQC of all abuse and alleged abuse. There was a registered manager in post who was known to people, relatives and staff. Staff told us they could approach the registered manager about any concerns and felt they would be listened to.

Systems were not in place to enable staff to speak up. Whilst people and staff did not raise concerns about this quality statement, the provider whistleblowing policy was out of date. The policy signposted staff to an organisation that no longer existed if they wanted to raise any concerns. The policy also signposted staff to raise concerns internally to job roles that did not exist. This meant the service did not have an effective whistleblowing process or policy.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider employed a diverse workforce who told us they had been made to feel welcome when joining the service. There was an equality, diversity and inclusion policy at the service which outlined the procedures and aims of the service.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance systems were not established or effective in assessing and monitoring the quality and safety at the service. Audits being completed were not effective in identifying shortfalls in areas such as medicines management, care records and risk management plans. The provider had policies and procedures, but these contained inaccurate information or information not relevant to this type of service. For example, some had been written for a care home and some contained signposting to organisations no longer operating. We found records contained inaccurate information which the provider had failed to identify and address. The provider had failed to make sure all notifications had been submitted to CQC as required by law.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Staff did not always work with healthcare professionals to make sure people’s needs were met seamlessly. For example, where a person needed equipment, records demonstrated staff had not liaised with healthcare professionals to make sure the equipment was sourced.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. The provider was not aware of good practice guidance and relevant legislation for the sector. The provider did not have any external support to help guide them on good governance and oversight of the service. Relevant guidance and resources had not been made available to staff.