Derby

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first inspection for this service. This key question has been rated requires improvement. 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 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 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.

Staff consistently described the organisation as supportive, respectful and focused on delivering good care. One staff member said, “We work together as a team… if we face issues, we come together to solve them.” Another told us, “There is a strong positive work environment, everyone is treated with dignity and respect.”

People and relatives also reported a caring, respectful approach, describing staff as kind, understanding and responsive. This shared commitment to kindness and teamwork supported a culture where people’s needs were prioritised. Staff consistently demonstrated compassion and pride in their roles, contributing to a shared sense of purpose.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders were described as approachable, supportive and compassionate. Staff told us they could speak to managers easily, and that leaders were visible and available. One staff member said, “The management team is approachable. I feel very comfortable contacting them about any issues.”

People and relatives also expressed confidence in managers, with one relative saying they would contact the manager if needed. Leaders demonstrated an inclusive approach that valued staff wellbeing and helped create a stable workforce.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff felt confident to speak up and raise concerns. The whistleblowing policy was clear, accessible and aligned with national guidance, and staff demonstrated a strong understanding of what to report and how. Staff told us they had no fear of repercussions, and that leaders fostered a safe environment for raising issues. One staff member said, “We can speak openly there is always a manager on duty if we need support.”

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 reported training, opportunities and support were provided fairly, and that leaders were inclusive and understanding of individual circumstances. This helped foster a sense of belonging and contributed to staff retention and morale. Relatives also noted staff brought diverse strengths that benefited people using the service.

The provider did have general responsibilities and basic systems and oversight around governance, however there was no specific audits in place for each area of service provision.

For example, although care plans were detailed and often good quality, there were no individual care plan audits, and no structured incident or accident analysis, meaning the provider could not demonstrate learning or recognise patterns of concern. Team meetings and our conversations with staff demonstrated learning was taking place, but this was not formally recorded.

One recruitment file also lacked full employment history verification, showing governance processes were not consistently identifying gaps. Therefore, despite a hands‑on registered manager, there was insufficient documented oversight, and improvements were not evidenced through formal systems.

We raised this with the provider, who acknowledged governance needed improving and agreed to strengthen systems and monitoring processes.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

People were supported to stay connected with their communities, attending day services, visiting the library, or maintaining routines that were meaningful to them. Relatives also confirmed the service liaised well with them and other professionals, helping ensure people remained integrated and supported in their wider networks.

Despite the provider focusing on continuous learning, innovation and improvement across the organisation they did not always evidence creative ways of delivering equality of experience, outcome and quality of life for people. The provider listened actively to our feedback based on this inspection and has made some improvement to their governance and oversight structure. They have also given assurances that this will be developed in the future too.