Hibiscus Domiciliary Care Agency

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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 64 (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 had a shared vision, strategy and culture. The provider had developed a vision for the future of the company The provider’s vision was to have a successful domiciliary care service which supported people in the community. The vision described having a competent workforce who helped people of all ages flourish and have enriched lives with good health and wellbeing. The provider had a business plan in place which set out the steps they had taken to improve the service. Staff understood the values of the company and worked to ensure people had good quality support and could describe the changes that had been made to achieve the goals of the business plan.

Leaders did not consistently ensure their knowledge and experience was accurate and up to date enabling consistently effective leadership in the service. There had been a safeguarding investigation conducted on behalf of the local safeguarding team. The provider had not recognised CQC should have been notified of this incident and investigation. The provider had however taken the appropriate actions to respond to the investigation and confirmed in future any contact with local safeguarding authorities would be notified as required. Staff gave positive feedback about leaders. One staff member told us, “We have updates and information on all kinds of new stuff all the time.” The provider was also supporting members of the management team to develop their skills with a view to taking on the registered manager role in the future.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider told us they had a whistleblowing policy in place, and they actively encouraged staff to speak up if they had any concerns. Staff told us they felt comfortable raising any concerns with the management team, but also understood they could raise these with other agencies if they were not listened to. People and relatives all told us they felt able to speak directly with the management team about any concerns and felt these would be addressed.

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 had systems in place to support staff. Staff told us they had opportunities to seek support through staff meetings and supervisions which were held regularly. The provider had an equality and diversity policy in place to ensure staff worked in an environment free from discrimination and harassment. Processes ensured staff were valued and treated equitably.

The provider’s governance systems did not always work effectively to identify areas for improvement and enable the appropriate action to be taken. The provider’s systems to ensure risks to people were managed were not consistently effective. The system had not identified where 1 person risks relating to diabetes had not been considered and planned for. Staff had a knowledge of the persons condition, and the person was able to manage their condition, however there were no references to this in the persons care plan. The provider took action to correct this on the day of the assessment site visit. Medicines audits were not consistently identifying when medicines stocks were running low enabling action to be taken to ensure people had their prescribed medicines. The system only identified the concern when the person missed having this medicine. The provider had taken action to prevent this from occurring again and we confirmed the person had come to no harm because of not having their medicine. Other systems in place were working well such as checks in recruitment practices, training completion and infection prevention control.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Partners told us the provider worked closely with them and were forthcoming in providing information and communicating about the service and people’s needs. The registered manager told us they worked with a range of different agencies in providing peoples care. Staff were also able to describe how they supported people working closely with other health professionals.

The providers systems had not always focused on learning and improvement across the organisation. There was a system in place to consider learning from incidents. However, where someone had falls these had not been captured in this system to consider any wider learning. The registered manager had not understood these falls should be included in their analysis however they confirmed the person had actions taken to prevent future falls and they would make changes to their analysis system to ensure any future incidents would be considered. Partners told us the provider worked with them and other external bodies to make improvements to the service. The provider had developed an action plan which detailed how they had made changes to the service and had made improvements in a number of areas including recruitment practices, training for staff and care planning.