Cardinal Care Services Ltd

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 assessment we rated this key question good. At this assessment the rating 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 the governance of the service.

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.

There was a shared view of what good care looks like and we found examples where staff showed flexibility to meet people's needs and preferences. However, we found the systems in place to create and sustain a consistent shared sense of direction were not always taking place. For example, team meetings were not regularly held, and supervisions were not regularly taking place.

Staff told us they felt well supported and the provider promoted a good work-life balance. However, the lack of regular supervisions and management oversight of knowledge and competencies gained via online training, did not always ensure staff who required additional support could perform as expected, for example, with record keeping.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People had completed questionnaires about the quality of their care and were involved in reviewing their care as well. Relatives told us they felt comfortable in raising any issues with the registered manager, and confident these would be acted upon.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Although staff told us they felt well supported and integrated in the team, we found staff’s protected characteristics were not always considered and appropriate action taken to support staff.

The governance systems and management systems in place required improvement. The registered manager had not been present at the service as often as previously. There were arrangements in place for the service to continue operating. However, we found these had not always ensured regular audits were completed in areas we found concerns during this assessment, such as risk assessments, medicines and staff training. We did not see any evidence of the nominated individual being involved in providing management oversight at the service.

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. In our review of people’s care records, conversations with management team and relatives, we found the provider was in contact with relevant health professionals to ensure people’s needs were met in a timely way. The registered manager worked collaboratively with other care providers when organising staff’s training.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. During this assessment, we found the registered manager had not always kept up to date with new requirements around staff’s training or the application of best practice guidance. The management team were responsive to assessment findings and feedback, and acted or told us the actions they would take in response of our feedback.