EveryDay

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

The service was not always well-led and has been rated requires improvement. We found a breach of regulation relating to records. Governance processes were in place, but these failed to identify and remedy the issues found at this assessment. Checks made on the service were not always robust. The service had consistent management who demonstrated caring values. However, some staff told us they had concerns about culture and did not always feel listened to. While people we spoke to said that they were happy with their care, our assessment found elements of the oversight of the service did not meet the expected standards. The provider was investing in new technologies to improve this but system were not yet fully impliemented. Improvements were being made in-line with a organisational risk assessment.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received mixed feedback from staff about the culture of the service. Some staff told us that they received support when required. They were able to provide feedback about the service to the management team and felt listened too. However, some staff told us that they had raised concerns, such as about people’s care and records and this had not been addressed. Some staff also told us they were not listened too when they took concerns to the management. The registered manager told us satisfaction surveys they received from staff were mainly positive. However, they would look at how staff support could be improved.

The services Visions and Aims placed people at the heart of the service. Service objectives were monitored through audits. However, we found that audit systems were not always robust to ensure the visions and aims of the service was followed consistently. These did not always ensure there was an open and positive culture at the service where all staff felt safe and listened too.

Staff gave mixed feedback about the management team. Some staff were positive about the support received. A staff member told us, “I feel the management team are very good and very helpful and supportive.” However, some staff also told us when concerns were raised, response or feedback was not provided to these concerns and when information was requested on care plans, this was not provided. A staff member told us, “Yes, I am able to make suggestions and raise issues via teams and via telephone when the service manager answers. They listen but doesn't always act on issues. I rarely get feedback. They say they are going to do something but rarely do.” Another staff member told us, “More managerial staff are quitting, and some buildings don’t even have an appointed manager, so care staff are feeling lost, as there is no leadership or communication.” Folllowing the assessment management told us, "Where we have management absences these have been covered by the Senior Operations Manager' and there were "Regular communication process which allowed normal communication processes to continue."

The management team were compassionate and knew the services, people and staff well. However, some shortfalls remained with risk assessments, training and staffing records and governance checks, which would require addressing to ensure people always received safe care and support. The management team had planned and were making improvements to the systems in the service. They had led a significant change management programme which involved finding additional resources to cover key who staff were involved in the programme. They told us, 'The digital transformation programme underwent robust scrutiny by the Board which included external experts support to develop the implementation plan.'

We recieved mixed feedback from staff. Most staff told us they felt they felt serious concerns were responded to and people were kept safe. Some staff felt processes for listening to staff could improve. Some staff told us they had raised issues that were not responded to. Management told us they asked for staff feedback, and they responded to concerns raised with them.

The provider had policies and systems in place, which aimed to foster a positive culture where people felt they could speak up and their voice would be heard.

The management team told us staff completed equality and diversity training, and they employed and supported a diverse workforce.

Training, policy and procedures were in place to support equality, diversity and inclusion.

The oversight of the service was not robust and did not identify all the issues found at this assessment. This resulted in a breach of good governance. The management team told us there was a quality assurance system in place and that they completed regular audits of the service. However, these systems had not identified that improvement was needed to records for recruitment, staffing and care. The provider had identified the need to improve and update systems generally. A new electronic system was being implimented. The registered manager told us that this system would include more detailed audits and provide better management oversight.

Processes were in place to check on the quality and safety of the service, but these were not always effective. Audits had been completed covering key areas, but these were not always robust. The registered manager told us the planned new systems contained audits that were more detailed, but these were not yet in use. The registered manager was responsive to feedback about the issues found during this assessment and took steps to address these straight away. Due to the lack of detailed audits and action plans we could not be assured that these issues would have been addressed if we had not raised them. Although there was no evidence anyone was harmed there was the potential for harm as checks did not always ensure staff have the correct records for recruitment, staffing support or guidance around care and support for people. This resulted in a breach of regulation 17, good governance. Following the inspection management acknolwedged that certain audits had been prioritised based on risk, as part of the digital tranformation. They told us the organisation had maintained external quality standards, including for quality management and health and safety.

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.

There were systems for learning, improvement and innovation however these were not always robust. Some staff told us systems for feedback and learning could improve. The registered managers told us about networks they were part of internally and externally to share learning and good practice.

Development plans were in place, but they did not address all quality issues in the service. Accidents and incidents were reviewed, and lessons learnt were shared with staff.