Care & Grace

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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 found the provider had failed to operate effective governance systems to enable them to assess, monitor and improve the quality of people’s care. Although the provider was in regular contact with people, relatives and advocates, their governance systems and processes did not support them in maintaining oversight of risks, performance and outcomes. People, relatives, advocates and staff were complimentary of the service and spoke highly of the provider. They told us how accessible they were and responsive to any concerns raised. The provider had failed to consistently follow their own policies and procedures which would provide them with effective oversight of the service. They reacted to situations but did not consistently act to prevent situations occurring and mitigate the risks to people. Care records lacked important information that would support staff to carry out their role effectively, possibly reducing the number of concerns raised. The provider lacked sufficient understanding of the regulatory requirements associated with their role. The provider took on board all the feedback given during the assessment.

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.

Staff reported they felt very supported by the provider and were clear the values of the service were to provide quality care. The provider encouraged staff to raise any concerns they may have, with them, but there was a lack of evidence to demonstrate actions taken and lessons learnt, in response to concerns raised by staff.

Supervision meetings with staff had commenced but there were no records of supervision meetings taking place prior to August 2024. Staff reported weekly staff meetings were now taking place and arrangements had been made for them to take place electronically, to enable all staff to attend and participate.

Staff spoke positively about the service and the provider. They told us they were always accessible to them and on the end of the phone. A member of staff described how supportive and responsive the provider was when they had experienced a family emergency. All staff felt they could speak to the provider regarding any concerns or questions they may have and they would be answered and acted on promptly.

The provider failed to utilise the systems and processes they had in place to provide them with effective oversight of risks, performance and quality of care. Quality assurance systems in place were underdeveloped, limited in scope and where audits and checks were completed, these were ineffective. The provider had failed to fully understand their obligations in terms of their regulatory duties. They could not be assured they had complete oversight of the service to ensure care was appropriately delivered and risks were well managed.

Staff told us that if they needed to speak up and raise any concerns they may have, then they would not hesitate to do so. They felt listened to by the provider. They advised us the provider was regularly on site and always accessible on the phone. During the assessment process, the provider was open and transparent and took on board the findings of the assessment.

The provider had a whistleblowing policy in place, but not all staff were aware of this. As accidents and incidents had not always been recorded, there was a lack of evidence to demonstrate these events had been investigated fully or responded to appropriately. We noted 1 formal complaint had been responded to and a full apology given to the complainant, but the provider had failed to follow their own complaints procedure as there was no documented evidence of an investigation into the concerns raised.

Staff felt listened to by the provider. The provider took steps to ensure staff felt empowered, that their voices were heard by the provider and were confident to raise any concerns they may have.

The provider ensured they were regularly available to staff, visiting them when they were supporting people and holding weekly meetings, providing staff with the opportunity to engage with them.

Staff were clear of their own roles and responsibilities but were not clear about who to approach with issues or concerns if the provider was not present. The provider was not fully aware of their role and responsibilities regarding governance of the service and was signposted to the CQC website to improve their knowledge and responsibilities of their role. Although the provider had access to a variety of audits which would provide oversight of the service, the majority of these had not been completed and those that had, failed to identify areas of concern found during the assessment.

The provider failed to establish and operate effective governance systems to enable them to assess, monitor and improve the quality and safety of the service. A variety of policies and procedures were in place but were not consistently followed. For example, the provider had failed to follow their own recruitment and selection procedure which would ensure recruitment processes were safe and robust; they had failed to ensure satisfactory references were consistently received for all prospective staff and explore any gaps in staff’s work history. Where audits and checks had been completed, they were ineffective and did not provide oversight of the service. There was no system in place to monitor call times which would ensure staff arrived on time and stayed for the correct length of time. Information held on staff rotas and timesheets was limited and unclear and suggested travel time between calls was not always allocated. We noted in some instances, staff were scheduled to be in 2 or 3 places at once. Accidents and incidents were not routinely reported or analysed for any lessons to be learnt and the provider had failed to notify CQC of a safeguarding concern. Risk assessments were missing and care plans lacked person-centred information that would provide staff with detailed information on how to support people safely, effectively and in line with their care needs.

People did not provide any feedback under this quality statement. Therefore, this has been given a score of 3.

Staff told us they worked alongside other health care agencies to support care provision. However, we received mixed responses from other healthcare professionals regarding the sharing of information.

One healthcare professional had a positive experience and spoke highly of the service, another had a less positive experience and raised concerns that information they had shared with the provider had not been included in the person’s care plan.

The provider had not established effective systems and processes to record contact with external teams and professionals, and associated outcomes and agreed actions.

The provider failed to ensure processes were in place to ensure lessons were learnt when things went wrong. Despite staff reporting they had regular meetings with the provider, there was no documented evidence of these meetings or any learning that may have been shared during these meetings. Opportunities to learn lessons from events were being missed. A member of staff had told us about a fall a person had experienced, but there was no evidence this was escalated to the provider which would provide them with the opportunity to investigate the incident and put in place any actions to reduce the risk of reoccurrence, or look for lessons to be learnt.

The provider had failed to put in place any formal procedures for actively encouraging, seeking or acting on feedback from people. People told us they were in regular contact with the provider, but there was no evidence of these conversations or actions taken in response. Despite a number of audits and policies and procedures being put in place, the provider had failed to utilise these. People told us the provider was responsive to any concerns they may have and dealt with matters quickly, but these events were not recorded. This meant opportunities were lost to review complaints, accidents, incidents and safeguarding concerns in order to identify any potential trends and areas for action. Although the provider took the concerns raised seriously and responded to them on an individual basis, they had failed to investigate root causes, patterns and trends to minimise the risk of further occurrences.