Rapid Review & Resettlement

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

A new audit and governance process was being used to assess the quality and safety of the service and care provided. Action plans were generated and reviewed to ensure required improvements had been made. The provider had sought assistance from stakeholders and professional organisations to help drive improvements. Relatives of people living at the location were complimentary about how the service was run and had found management to be open and approachable. People, relatives and staff ‘s views were regularly sought, and staff told us they felt confident in speaking up and reporting any issues.

This service scored 71 (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 sought to involve staff in the operation of the service, by seeking their views and opinions and sharing what actions would be taken to drive improvements. The provider was mindful of the importance of a good culture within the service. As a result, they used a specific questionnaire to gather staff’s views on the culture of the organisation. Questions included whether staff felt valued in their role, if there was a proactive culture of safety based on openness and honesty, if staff were confident in raising concerns, and if they felt listened to. The questionnaire had last been circulated earlier this year in 2024, with responses being mostly positive.

Monthly team meetings were completed, during which staff and management discussed people’s care and support, any improvements required, lessons learned, and also used the time to refresh staff’s knowledge of particular areas, such as safeguarding and fire safety. Actions were set and agreed at each meeting. These were reviewed as the first agenda item at the next meeting.

The location did not currently have a registered manager, and the nominated individual (NI) was currently completing this role. The NI told us, “Following the last inspection, we reviewed the situation. We have since had difficulty identifying and recruiting the right person to the [registered manager] role. We have been actively looking over the last 4 or 5 months without success. In the interim, I have stepped into the role.”

There was a clear management structure at the location, and the NI was being supported by an area manager, who previously worked as an assistant manager at the Rapid Review & Resettlement service, so knew the service and staff well. There was also now a service manager in post, who was the immediate line manager for the care staff. Staff had welcomed this change, with one staff member telling us, “I feel now that the service manager is in place, it has a leader at the head of the service. Prior to this, it was overseen by two senior carers.” Relatives told us they found management to be open, responsive and led the service well. Staff reported the service was well-led, with management being approachable.

Staff told us they felt able to raise concerns and that they would be listened to. One staff member stated, “Yes I 100% do. I feel I have raised concerns in the past and have been heard, and also had support to make a change that would better the service.”

The provider had an up to date Freedom to Speak Up and Whistleblowing policy, which had last been reviewed in July 2024. The policy had been linked to the relevant Quality Statements, to help ensure these were being met. The provider had introduced Freedom to Speak Up Guardians, who acted as the first contact for staff who may want to raise or discuss any concerns, and who could answer any questions they had about processes. At the time of the site visit, it was not clear who had been given this role, however, following the visit the nominated individual confirmed this would be the registered manager. A speak up poster had been created, which contained contact details for all registered managers who worked for the provider, as well the provider’s human resources team, in case staff felt more comfortable speaking with them.

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 provider had implemented a new audit schedule and process since we last inspected the service. The schedule detailed the audit or monitoring task, who was responsible, and frequency. A separate compliance planner was used to assist with the scheduling of audits, breaking these down in weekly, monthly and quarterly tasks. The provider completed spot checks, which were used to ensure staff were carrying out care and support as necessary and all required tasks had been completed. Senior staff and managers from other services owned by the provider supported this process. Since our last inspection in August 2023, a new audit schedule had been implemented, with checks being completed a different times of the day and week, to get a more holistic view of how the service was operating.

We reviewed the last 2 months audits and found these had been completed consistently. All monthly audits were compiled onto one ‘Service Audit Document.’ The document listed the areas to be inspected [audited], key areas to look at, findings, actions required and completion date. Areas covered by the audit included health and safety, fire safety, environment, risk assessments, health action plans, medication, nutrition and hydration, daily records, staff training and supervision. Any identified issues were added to the action plan at the end of the document. Alongside the above monitoring processes, a number of meetings were also held which looked at quality, governance and operational matters. One meeting focussed on feedback from people, relatives and stakeholders, audit feedback, and key performance indicators, whilst another concentrated on monitoring, improvements and adherence to regulation.

Relatives of people living at the service were complimentary about how the service was run and had found management to be open and approachable. People, relatives and staff ‘s views were regularly sought, and staff told us they felt confident in speaking up and reporting any issues.

The provider had employed the services of a healthcare compliance company to review and advise on governance processes and ensure the provider was meeting regulations and adhering to best practice. The provider was also working closely with the local authority performance and quality team, to help drive improvements in the service.

The provider worked with a number of partners and stakeholders to support the provision of care. The local authority did not report any concerns about the location to us.

Regular meetings were held with a variety of stakeholders to review people’s care and plan for their future. This included Integrated Care Boards, social workers, advanced practitioners and commissioners.

To support the location with making improvements and meeting regulation, the provider had employed an external consultancy firm, who had completed their own audits and monitoring, generated actions and supported the development of current systems being used. We observed a number of examples of innovative practice during our on-site visits, many of which have been referenced in other quality statements in this report. These included the building of a bed base with in-built epilepsy sensor, to remove the need for intrusive observations of a person at risk due to epilepsy, and the installation of an indestructible toilet to ensure a person maintained access to a toilet overnight, whilst minimising the risk of damage to themselves, other people and property.

The provider had a Service Improvement Plan (SIP), which they used to monitor and record actions taken to address issues noted at the previous CQC inspection and ongoing monitoring by the local authority. We noted the SIP was not currently used to document actions identified through the provider’s internal audit process, which each audit having its own individual action plan. During the assessment, we discussed with the provider the benefit of collating all actions on to one document to help improve oversight. The provider agreed to do this moving forwards.