Diverse Care Services

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. At our last inspection we rated this key question requires improvement. At this inspection the rating has remained as requires improvement. This meant the service management and leadership did not always support the delivery of high-quality, person-centred care. We found that audits of care records and risk assessments were not always robust.

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.

Our last inspection identified that risks assessments needed improvement. At this assessment improvements were still needed to the systems in place for the oversight of the management of risk. The provider openly discussed with us where gaps in their records and systems existed. There was a willingness to improve. The provider did welcome and support an open culture which was supported by staff feedback to us. Staff were confident to identify poor practice and told us concerns would be acted on by management. People and relatives told us staff were kind and compassionate. Staff and management fed back passionately about the care being delivered to people and spoke fondly of the people they were supporting. Staff were able to share with us examples of where they had gone above and beyond their role to do things for people. This included supporting people to attend places of worship and cultural events, celebrate birthdays and helping a person to have work done to their garden so they could access it safely and enjoy it.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support. Leaders were visible within the service and led by example to their staff team, demonstrating inclusive behaviours. There was a stable management and staff team. People, their families and staff knew who the management team were, and how to contact them. People and relatives told us the management team was caring and approachable. A relative said, “Some staff go over and above and some just do the job. I have no concerns at all. Some of the staff are diamonds.” Staff knew their roles, responsibilities and how to support each other. They told us they felt supported and valued by the management team.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt confident to report, whistle blow and raise concerns if needed. Staff were positive about the management who were open, listened and acted upon feedback. A staff member told us their training included safeguarding and how to keep people and themselves safe. Another staff member told us about a safeguarding concern and how it was dealt with successfully. The provider had processes to inform staff how to whistle blow. Staff were able to raise concerns and had their practice observed to ensure any training and learning was applied. The provider had developed systems and processes to gather feedback from staff including completing surveys. A recent survey had identified some additional staff training needs and this was acted on.

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. There were systems in place for matching staff to people, for example, if a person spoke a particular language or if a person wanted a male or female member of care staff. There were processes for staff recruitment and induction. Staff received training relevant to their roles.

The provider’s governance systems were not always effective. These systems had not enabled them to identify and address the shortfalls in quality and risks we identified during our assessment. Audits had failed to identify people’s care records did not always include clear and accurate information and guidance for staff in relation to the management of specific risks and health conditions. In addition, there were some inconsistencies in recording in 1 person’s care records regarding their mental capacity. Records were not always clear about the involvement of healthcare professionals in people’s care. Care records for people supported who had a learning disability and autism did not always include clear information for staff about their communication and behaviour support needs. Notifications were submitted to CQC as legally required; however, we did discuss points of clarification with the provider regarding these. The provider had a system for monitoring incidents. People told us they were contacted to ask for feedback, and this was acted on. Unannounced spot checks took place in people’s homes to check on the quality of care.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, the involvement of external health care professionals was not always evident in people’s care records. It was not always clear how the provider engaged others, so people could thrive and develop skills. For example, the involvement of district nurses, and the mental health team was not always clear in people’s care records. Staff told us they could make referrals to health and social care professionals via the management team. Relatives we spoke with and the provider confirmed relevant health and social care professionals were involved with people’s care. We received only limited feedback from health and social care professionals we contacted as part of the assessment process. One healthcare professional told us they worked well with the provider and had no concerns.

The provider’s systems and processes for assessing and monitoring the safety and quality of people’s care were not sufficiently robust or effective. Some shortfalls in the quality and safety of people’s care were found at this assessment. Our assessment identified a breach relating to the provision of safe care. The management team demonstrated they wanted to drive the improvements in people’s care and told us they were committed to doing this. The service supported some people with a learning disability and autism and was aware of current best practice guidance including right support, right care, right culture. However, care records needed some development, so they better reflected this guidance and demonstrated how they were enabling people to promote their independence, identify pathways to future goals and enjoy a full life.