Versita Care 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 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 requires improvement. At this assessment the rating has remained requires improvement. The service was in breach of legal regulations in relation to good governance.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The challenges and needs of some people had not always been understood and met fully. The provider’s statement of purpose set out their aims and objectives for the service. It stated the provider supported adults with a learning disability, mental health and forensic needs, autism and challenging behaviours. The provider informed us they had applied for the service user band of mental health when they first registered. However, they had not identified that the CQC website did not confirm they had this specialism. The provider has now submitted a new notification to add this service user band to their registration. The provider had successfully supported people with some mental health diagnoses over some years. Although we were satisfied the provider had the skills to support some people with a mental health diagnosis, staff lacked the required skills and training to support people with other specific mental health diagnoses safely. As the provider had expanded their provision, they had not ensured they were ready to support the needs of some people as per their aims and objectives. However, people whose primary needs related to their learning disability or autism were overall at the centre of their support. The registered manager was visible within the service.

Leaders had not always delivered their organisational vision effectively. Risks to all people had not always been managed. There was a management structure in place and the registered manager had professional qualifications, experience and knowledge in relation to supporting people with learning disabilities. They were supported by both the managing director and the deputy manager in the daily running of the service. There was also a Director of Mental Health. However, we were told they were only physically onsite for two days a month, to meet with people, update care plans and train staff. The shortfalls we found indicated this was likely not a sufficient level of onsite mental health leadership and oversight for the complexity of the mental health needs of some of the people supported. The provider also drew on the expertise of a nurse to complete their weekly medication audits and to provide guidance regards people’s physical health needs. However, the provider was open to listening to feedback to drive improvements and has already started to take action to address the issues identified. There was a focus on how staff could support people to live the life they wished as part of their community.

People and relatives could speak out and most, but not all felt they were listened to. The provider had policies in place to enable staff to speak out, such as their whistleblowing and freedom to speak up policies. Staff told us the provider was approachable, and they could raise any issues. There were processes for people and relatives to raise issues, such as reviews and surveys and they could speak directly with the registered manager. Although the provider understood there must be a separation between the care a person receives and their accommodation. The 2 companies responsible for the provision of people’s accommodation and people’s care had the same 2 directors. The provider was aware of this issue and has advised CQC they are seeking to address this to ensure legal requirements in relation to their registration were met.

The service worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they felt they worked in an inclusive and fair culture. The provider had policies and processes in place to capture and monitor data about equality, diversity and inclusion.

Systems for identifying, capturing and managing organisational risks and issues were not effective. Legal requirements about notifications were not consistently understood. Record keeping did not always meet legal requirements. Although the provider had an audit matrix, the audits completed were not robust and had not identified the issues we found at this inspection, in relation to safety, safeguarding, staff training, consent, MCA assessments, DoLS, medicines and staff recruitment. The provider’s audits did not address all of the above areas. Processes to ensure staff’s pre-employment checks were completed thoroughly and to ensure staff were still legally entitled to work in the UK were not robust. There were contradictions in some people’s care plans. Some aspects of people’s records referenced other people. CQC had been notified of incidents which involved the police, but we had not received any safeguarding notifications as legally required. When safeguarding’s had been raised about people either by the provider or others. However, the provider displayed their last CQC report both online and at their location as required.

The service understood their duty to collaborate and work in partnership. They shared information and learning with partners and collaborated with them. The provider and staff worked with a wide range of relevant external stakeholders and agencies across learning disability and mental health services. To support the provision of people’s care. Staff worked with others to enable people to live they chose.

The service had good external relationships. The provider and staff worked with stakeholders and agencies, to support the provision of people’s care. Overall, the model of care for people with a learning disability was aligned to current best practice guidance right support, right care, right culture. Feedback, regarding people whose predominant needs related to their learning disability were positive overall. Further learning was required to enable staff to effectively support people with certain mental health diagnoses.