Blossoming Hearts Care Agency 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. 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.

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 provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. People and their relatives told us the provider and the staff were open and honest.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. For example, they did not have effective governance systems in place in relation to medicines, accidents and incidents and staffing on care calls. Leaders were visible and contactable by staff and people who use the service. The provider accepted our feedback and said that they would make changes to improve the service, but there were no processes in place for them to identify improvements needed to the service at the time of our inspection. This placed service users at increased risk of harm.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People and their relatives told us that they always felt able to contact the registered manager with concerns and that they felt they would be listened to.

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 registered manager said they worked to support the cultural and diversity needs of their staff. They challenged discrimination experienced by staff.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. During the assessment the service did not have clear systems and processes in place for monitoring incidents and accidents. The registered manager also did not have a good understanding of what they should be notifying CQC about or when to make the notification and supervision records did not evidence meaningful conversations. We also found not all staff competencies had been stored in the correct place. This made it difficult for the registered manager to access this information when asked. For example, when they were not able to find staff competencies around medicine administration or information regarding incidents and accidents.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The registered manager worked with people and their relatives and contacted other professionals when needed.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. The provider did not have effective systems and processes in place to evidence that they were learning form incidents. They did not audit the service to ensure they knew where they needed to make improvements or where things were going well.