London Care (Ensham House)

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 good. At this assessment the rating has changed to requires improvement.

This key question has been rated requires improvement. The culture in the service needed to improve and the provider did not have an effective way to assess, monitor and improve the quality and safety of the service provided.

We found the provider was in breach of the legal regulation in relation to good governance.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although the provider had a vision, strategy and culture which was shared with staff through team meetings, staff did not feel there was a positive and open culture at the service.

Staff expressed concerns about feeling unheard. Feedback indicated a perception of management not valuing staff input. Comments suggested staff felt their views were dismissed and that management was resistant to listening.

We shared the concerns expressed to us by staff with the registered managers’ line manager whilst we were on site.

Despite the above, people using the service told us that there was a positive culture within the service and they enjoyed living there. They said care staff treated them with respect and dignity. Comments included, “[Registered Manager] is the care manager and [Name] is the house manager – they are fine. They’ll listen”, “I’ve got my own flat, care staff are OK, they are good”, “Staff help me, they are fine, they chat and make me laugh” and “I like it here, I like the independence.”

Care worker meetings were held every quarter. These were used as a platform to share any company-wide initiatives and updates. The provider’s values were discussed during regular supervision/engagement meetings where staff were reminded about these and were given the opportunity to demonstrate how they had met these.

The provider had leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience to lead effectively, however some improvement was needed in how they managed the staff team.

The feedback we received from staff reflected this. They told us the managers could do better at listening to them and taking their suggestions on board as reflected in this report. For example, staff told us the managers did not act promptly to adjust the rota or resolve their concerns about the phone system which was linked to both people’s call alarms and the entrance bells.

Managers held regular supervision or ‘engagement’ sessions with staff. These meetings were used to ask care workers their views on a number of topics including their role satisfaction and identify any areas for development. They were also used as a way to remind care workers about their responsibilities under safeguarding, recognising abuse and understanding of their role.

The managers and staff understood their responsibilities in relation to regulatory requirements around notifiable incidents. Our records indicated they continued to notify the CQC in timely manner about any incidents and events they were legally required to.

There had been some changes to the managerial structure recently with a new area manager allocated to the service. This information was shared with the staff team including a new escalation procedure for raising any concerns.

The provider did not always foster a culture where people could speak up.

Staff told us they did not feel free to speak up and did not feel listened to by management. Comments from staff included, “I keep my views to myself”, “The manager doesn’t listen to our concerns.”

We shared the views expressed to us by staff about the culture at the service with the area manager during our on-site assessment.

Feedback was sought from staff through individual supervision and team meetings. The most recent care worker meeting minutes showed that staff were reminded about whistleblowing and included details of an independent organisation where whistleblowing concerns could be raised.

The area and regional manager had chaired a ‘safe space meeting’ for staff to voice concerns and provide feedback without the presence of the registered manager, for staff to provide feedback and bring forward any points of discussion. A number of concerns were bought forward for them to consider and respond to. This demonstrated staff were given an opportunity to feedback and give their views, although they told us they did not always feel listened to.

The provider gathered feedback from people through surveys, known as ‘voice of customer surveys’ which were completed on a regular basis. People were asked if they felt safe, supported, connected and in control. Records showed that where concerns had been raised, these were followed up.

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.

Staff were provided support through relevant training and supervision to inform their knowledge and understanding of equality, inclusivity and fairness in the workplace.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

One of the main areas of concern that were raised by both people and care workers was the emergency call bell system. People told us that the response from staff when they requested help was poor and care staff told us the system was not effective. There had been recent provider concern for the provider’s lack of responsiveness to the emergency buzzer which was upheld after an investigation. Despite this, the provider did not have an effective system of monitoring response times to the emergency call bells. Although they were able to request this data, the provider did not routinely analyse it to monitor whether staff were responding to this in a timely manner. The provider did not monitor the system to determine its potentially detrimental impact on the ability of staff to provide timely and consistent care and support to people.

The regional team completed annual medication and a ‘branch’ audit, the most recent one was in April 2024 in which the service had met the provider’s KPI standard. These had identified some areas of improvement which were followed up by the quality team.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

Managers and staff told us they worked closely with various external health and social care professionals and bodies who they regularly consulted and welcomed their views and advice.

The provider focused on learning across the organisation and local system. They encouraged ways of delivering equality of experience, outcome and quality of life for people.

Managers and staff recognised the importance of learning lessons and continuous improvement to ensure people living at the scheme received good quality, safe care and support.

The provider carried out surveys to gather feedback from people. We saw evidence where people had raised any issues or areas of improvement, these were put into an action plan to be followed up.

There was an improvement plan in place which was overseen by the area and regional manager. Some of the actions identified for improvement in this included reviewing risk assessments to ensure they were up to date, ensure medication reviews are taking place and completing more spot checks.