Care Gems

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

We identified 2 breaches of the legal regulations. The provider’s quality assurance systems were not effectively identifying shortfalls in the quality and safety of the service. However, people were happy with the service they received. Staff felt well supported and worked with professionals to promote good outcomes for people. The provider was passionate about caring for people and wanted to learn and improve the service.

This service scored 62 (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 visions and values and these were shared with staff. The provider told us they liked to get people who use the service and staff involved. One staff member said, “I think the intentions for the clients are to go above and beyond”.

The provider shared their visions and values with us. These were discussed at staff meetings

Staff were positive about the leadership of the service and felt the managers were caring. Staff told us they felt listened to. One staff member said, “I absolutely love it. I love what I do, I love the company I work for. They listen and care for the clients and if you have any issues, they address them.”

The provider delivered care to people regularly and worked alongside the staff team. However, they did not have effective oversight of the service.

The provider employed an assistant manager and office support staff. The staff team told us they were supported by the provider.

Staff told us they were able to raise any concerns and felt they would be listened to. The provider told us they had an open-door policy so staff could speak with them. They told us staff had not raised any concerns about people who use the service or other staff. When a staff member said they felt uncomfortable during a visit, the provider told us they had taken action. However, they had not recorded this discussion.

There was a whistleblowing policy in place so staff knew how they could raise concerns.

All staff we spoke with told us they felt they were treated fairly. One staff member commented, “100% staff are treated fairly and equally.” The provider told us they treated staff equally and gave us examples of how they had made reasonable adjustments to support staff.

The service had an equality, diversity, and inclusion policy.

The provider described the arrangements they had in place to formally assess, review, and monitor the quality of care provided at the service. They told us the management team carried out audits and these were checked by the provider. However, we found the systems were not effective.

There was limited oversight of the quality and safety of the service. Documentation requested by the CQC was not always available for us to review. The provider’s audit system had not identified the shortfalls we found during this assessment. Records were not always clear, detailed, or up-to-date. We found information that had been discussed had not always been recorded. The provider had not notified the CQC of all incidents, as legally required.

When reviewing people’s care needs, we identified the service had not applied for some service user bands to ensure they were correctly registered for the care they were delivering. Following a discussion with the provider, they told us they will put in an application to add the relevant service user bands.

People told us they were able to speak with the provider or management team and found them approachable. Comments included, “I’ve been receiving care for just over a year. It’s brilliant. No complaints”, “approachable and easy to get hold of” and “We talk all the time. Issues are dealt with at the time”.

Staff and the provider described how they contacted health and social care professionals when people’s needs changed, or they needed support. The provider had links with the local community such as the college and the community centre.

The provider had a recent visit from the local authority quality assurance and improvement team who had offered them support.

Referrals were made to health and social care professionals to ensure the best outcomes for people.

The provider told us they were committed to learning to ensure they could look after people in their local area.

System and processes had not been effective at identifying areas of improvement we found throughout this inspection. We identified shortfalls which have led to breaches of regulations. This meant quality performance had not always been assessed, potential risks to people were not always identified and lessons learned to drive improvements had not always been possible. The provider was receptive to feedback and told us they would make the required improvements.