Creative Care and Support Limited

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 good. At this assessment the rating has remained/changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The provider was in breach of legal regulation in relation to governance at the service.

This service scored 54 (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 core values which reflected transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff received these at the start of employment as well as completing a range of related training to support them understand the challenges and needs of people and their communities. However, during this assessment, we received mixed feedback from staff regarding changes over the past year and their awareness of the future vision for the service.

Leaders told us they were committed to ensuring staff felt supported, listened to and that they promoted a positive culture. However, feedback from several staff highlighted concerns with communication, support and a poor experience of contact with the office leaving them reluctant to visit or telephone. We received reassurance from the senior team that they would explore concerns raised and would extend plans for staff engagement with the new office move to improve relationships and communication with all staff.

Systems were in place for people to speak up and for their voices to be heard. However, some people and relatives we spoke to felt that they were not always listened to or action taken on some of the issues they had raised. The provider agreed to review systems in place including options within the new system which would facilitate better communication and involvement for people and relatives in their care.

The provider told us they valued diversity in their workforce. They told us they worked towards an inclusive and fair culture by improving equality and equity for people who worked for them and adjustments made where possible to support staff with their personal circumstances. However, we received mixed feedback from staff with some staff feeling not valued and raising concerns about requests for cover, short notice changes and personal circumstances not being considered.

The provider failed to ensure that effective governance and audit systems were being completed. Paper records had been removed before the electronic system had been updated with essential information for staff on how to support people safely and mitigate risks. The quality monitoring systems in place had not identified shortfalls found during this assessment or were not effective in identifying themes and trends. The lack of effective monitoring systems meant issues may not be identified and lessons may not be learnt when things went wrong. This evidenced systems and processes of governance were neither robust nor effective. The provider took immediate action to address these issues. They provided reassurance that the new electronic recording and management system once embedded and the recruitment of a dedicated staff to oversee compliance would improve overall oversight of the service and increase quality of support provided.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Partners were positive of their experience of working with Creative Care and Support Limited. The senior team had a strong commitment to improving the service and were open to suggestions for improvement, recognising the importance of joint working with partner agencies. The provider told us that their investment in new technology was fundamental to increase their ability to monitor and improve care.

Systems in place at the time of assessment did not provide sufficient oversight of the service. This reduced the ability of the provider to review information and complete lessons learned, presenting a potential risk to people. Whilst we did identify shortfalls during this assessment, the provider was responsive to our findings and acted urgently on key areas of improvement. Evidence was provided during and following the assessment of action taken and assurance given that the new electronic recording and management system being implemented would provide more detailed analysis of information across the whole service and ensure improved outcomes for people.