HLC Care Agency Ltd

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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

The provider and registered manager failed to ensure they implemented a positive culture within the service. Quality monitoring of the service was inadequate: leaders had failed to ensure governance systems were in place to identify the serious concerns we found during inspection. The registered manager was not competent in their role, they had failed to follow regulations and we did not have assurances regarding their integrity. We found three breaches of the legal regulations in relation to governance, notifiable incidents and failure to display CQC rating at the registered office.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us there was a positive culture at the service. However, we found this not to be the case. Staff did not have the opportunity to formally feedback any concerns or areas for improvement. Not all staff knew people well and how they wanted to be supported.

The registered manager did not have effective systems in place to mitigate the risk of a closed culture within the service. A closed culture means a poor culture that can lead to harm, which can include human rights breaches such as abuse. The registered manager did not demonstrate a positive listening culture that promoted and understanding between them and people using the service. For example, systems were not in place to regularly gather and review feedback from people and staff. The registered manager had not ensured documentation was person centred, for example, language used was not always empowering or positive.

The registered manager and client welfare officer were not open and honest with us during the assessment. The registered manager told us that a staff member never had any time off, this included annual leave or sickness, however daily notes detailed they did have time off. The registered manager was unable to tell us who carried out the care visits when the staff member was not there.

The registered manager and client welfare officer did not have the experience, capability and integrity to ensure the organization values were upheld and risks to people well managed. We were not assured with the registered manager’s integrity during the assessment, they were evasive when we asked questions about staffing and contingency plans when staff were sick or on annual leave. The registered manager could not provide us with evidence or answers regarding staffing at the service. The registered manager did not lead by example, they lacked knowledge around governance and quality assurance to ensure people received compassionate and safe care and support.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager and client welfare officer provided very little assurance regarding their governance and oversight of the service. The registered manager did not know how to interpret the care notes and was unaware of the detail within the care notes.

The registered manager did not have systems in place to identify the serious concerns that were found during the assessment. The registered manager had not implemented any quality assurance systems to ensure they had sufficient oversight of the service. We asked the registered manager for their quality assurance audits, however they were unable to evidence that they were in place at the time of the assessment. The registered manager failed to ensure care and support plans were reflective of people’s current needs and that they were regularly reviewed to reflect any changes to people’s care and support needs. The registered manager failed to ensure robust recruitment checks were carried out to ensure the suitability of staff and safeguard people from potential harm or abuse. The registered manager and client welfare officer had no oversight of people’s care calls, they were unable to evidence that care notes were reviewed to pick up any concerns or identify any trends or patterns that they may need to take action on to keep people safe. The registered manager failed to implement relevant or mandatory quality frameworks, recognised standards, best practices or equivalents to improve equity in experience and outcomes for people using services and tackle known inequalities. For example, potential barriers to people had not been fully considered, such as communication barriers. The registered manager did not understand their regulatory responsibility regarding submitting statutory notifications to the Care Quality Commission. For example, we identified incidents that met the requirement for a notification to be submitted to CQC, the registered manager had not submitted any notifications to CQC.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff and leaders did not have a good understanding of how to make improvement happen within the service. For example, the registered manager had not facilitated regular staff meetings. The registered manager also failed to recognise the improvements that were needed to ensure documentation, such as care plans, were reflective of people's currents needs.

The registered manager had failed to ensure they addressed and learnt from shortfalls within the service and make the necessary improvements to ensure care and support for people was safe. At the last inspection, the service was rated requires improvement. The registered manager had not instilled a culture of learning and improvement to ensure enough improvement had been made to reflect the characteristics of a good rated service. The registered manager had failed to address previous concerns found in the last inspection. Staff were not supported to prioritise time to develop their skills around improvement and innovation. For example, there were a number of gaps within staffs training that were necessary for them to carry out their role and support people safely. The registered manager did not provide formal processes to encourage staff to speak up with ideas for improvement and innovation and actively invest time to listen and engage. For example, staff meetings were not held regularly.