Abihealth - Southwest Office

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• 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 reviewed 7 quality statements relating to shared direction and culture, capable and compassionate leaders, freedom to speak up, workforce equality, diversity and inclusion, governance, management and sustainability, partnerships, communities, and learning, improvement and innovation. We found staff and leaders demonstrated a positive, compassionate and listening culture. There was a clear strategy and business plan in place which outlined the organisation, values, aims and mission. Staff and leaders had been provided with appropriate training to be effective in their roles. Systems were effective in making sure people’s records were kept confidentially. There were mechanisms in place to allow people, relatives and staff to speak up and have their voices heard. There were policies and procedures in place to support workforce equality, diversity and inclusion. There was evidence of the provider liaising with various health professionals to ensure safe care and treatment for people living in the service. There were governance, management and accountability arrangements in place. However, we found some audits completed by the provider were not effective and had not identified some of the concerns we found. This was in relation to medicines optimisation, care plans and risk assessments. We found the systems and processes initiated during our assessment needed to be more embedded and sustained to ensure they were effective.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff showed an understanding of the organisation’s values, aims and visions. One staff member told us the organisation “had a listening ear, they want you to get to be your best, they make sure you have the right training. Trust is important too, so they trust you to do your job and do what is best for the people. They help with your wellbeing to be in the best mindset for yourself and your people.” Leaders told us they get feedback from commissioners about the needs for the local area and the current priorities so this can be fed into the strategy. For example, staff must have a minimum level 3 NVQ qualification in care, so they pay for this for staff on sponsorship. They also told us “We complete values workshops with our staff, so they are aligned with those. We want to empower staff to ensure they are aware of what we are trying to achieve. Visions, aims and values are discussed during supervision.”

There was a business plan in place which had planned for a 3-year term. The plan outlined the priorities, values, mission, support for people and staff as well as the financial projections for the organisation. The manager demonstrated their commitment to quality services and told us about some of the improvements they had made so far. A specialist domiciliary care recruitment agency was commissioned to fill the recent manager post. They told us that the provider had “set out the vision, mission and values of the service and detailed in great length what quality, skill set, experience and personality [person] expected to find in the people to lead his services.”

Staff told us leaders were visible and they had their contact details to approach them if they had any concerns. The manager had only been recruited a few months before the assessment commenced and was going through CQC’s registration process to become the registered manager. They told us they had received support from the senior leadership team since they started in their role. The manager had built up good relationships with staff during a short period of time and staff provided positive feedback about the manager particularly around their knowledge and skills. Staff told us they had learned a lot since the new manager had been in post and there had been positive changes.

Leaders were knowledgeable about the issues and priorities for the quality of the service. Leaders demonstrated a clear understanding of how poor culture could affect people’s care. The manager had been provided with training to be effective in their role and had previous experience of working in registered services.

Staff told us they were able to speak up and have their voices heard. Leaders told us they had mechanisms in place to allow people, relatives and staff to speak up and have their voices heard.

There was a whistleblowing policy and procedure in place which staff had access to. Supervisions showed staff were able to have their voices heard.

There was an example from a leader where the provider had made reasonable adjustment for them. Most staff were working on a sponsorship licence from overseas and told us they had not experienced any discrimination towards them. They were positive about their experiences from an equality, diversity and inclusion perspective.

There were policies and procedures in place to support workforce equality, diversity and inclusion.

Staff and leaders understood their roles and responsibilities and had opportunities to discuss their roles during supervision and weekly team meetings. Leaders told us they were focused on improving governance and there were plans in place to address this. However, staff could not demonstrate they were aware of relevant National Institute for Health and Excellent (NICE) guidelines.

Systems were effective in making sure people’s records were kept confidentially. Staff had received training in data protection. Audits were being completed; however, we found some audits were not effective and had not identified the concerns we found during the assessment. This was in relation to care plans, risk assessments and medicine optimisation. Processes were not adequately in place to ensure people received their medicines safely. The manager had already identified where improvements were needed and had introduced new systems and processes to ensure the service was effective. However, these systems and processes were newly implemented from April, when the manager joined the service and needed more time to become embedded and sustained to ensure they were effective.

People told us the service worked with other providers, so they received the support they needed. Most people told us that family contacted professionals on their behalf.

Staff and leaders told us they worked with a range of stakeholders and professionals to help make sure people received good care. Leaders told us they had been involved in local provider forums. During these forums they contributed feedback on the fair cost of care and managing employees through sponsorship. They were provided with positive feedback about their support for sponsored staff which helped other providers.

The local authority quality team had worked with the service to complete a quality audit. There was evidence of actions being completed with some still under review.

The provider liaised with various health professionals. The service was registered on the local authority homecare alliance framework so people could get up to date information on homecare service and guidance about local authority funding.

The manager told us about their future plans to develop the service and provided an overview of the systems and processes they had introduced. Staff were able to offer suggestions for improvement and learning during supervisions and team meetings

The provider was aware of Care Quality Commission (CQC) new ways of working and understood the new framework. Staff had received training relevant to their roles. There was evidence of the manager providing guidance to staff from the ‘Department of Health and Social Care’ and ‘Skills for Care’ to expand their knowledge. There was evidence of reflective practice where things had gone wrong. The manager had introduced lessons learned feedback sessions with staff across the organisation to share experiences, knowledge and direction going forward. The provider told us they had issued satisfaction surveys to identify learning from people’s experiences. At the time of this assessment, responses had not been returned.