Three Cups

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.

This is the first assessment for this newly registered service. This key question has been rated Good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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.

The provider regularly recognised and celebrated the achievements of people and staff, including personal milestones and wider contributions. The service also promoted inclusion by celebrating people’s and staff’s diverse cultures, religions and backgrounds through events and activities. This helped create an environment where diversity was respected and valued. Policies and procedures supported effective communication in these areas.

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.

Staff gave positive feedback about the management team and said the open-door approach helped them raise concerns and suggestions, which were addressed promptly. One staff member said, “Management are always available to talk to. I know I can ask for support and I will receive it.”

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

Staff understood the whistleblowing policy and were confident to raise concerns internally or externally if needed. They told us the service promoted an open and honest culture where concerns about unsafe or poor practice could be raised without fear of negative consequences. One staff member said, “We can express concerns without worrying about any negative outcome.”

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.

The provider promoted equality, equity and inclusion through policies and practices that supported equal opportunities and reduced barriers for staff. Staff felt valued, supported and respected by management, and described the service as well managed, supportive and focused on quality, safety and improvement. One staff said, “The management team is supportive, approachable, and professional.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Family members gave positive feedback about the provider and the quality of care. One relative said, “The staff are very caring and keep us informed. We feel confident our family member is safe and well supported.”

The provider had systems to monitor quality, safety, risks and performance, supporting effective oversight and consistent care. Regular care plan audits helped ensure records reflected people’s current needs and preferences. Leaders understood their regulatory responsibilities, and staff received clear guidance to carry out their roles effectively.

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.

The provider worked with partner agencies, including psychology teams, GPs, occupational health, the local authority and health professionals, to reduce barriers and delays in accessing support. Information was shared appropriately, and learning from incidents was communicated with partners to support collaborative improvement.

A care community nurse told us, “The care was very person centred, and any clinical recommendation were adhered to.”

Another professional told us, “I have found staff to be excellent at completing agreed tasks and actions. Communication has been clear, timely and focused at all times. I have always felt staff kept people’s best interests at the forefront. To date, I do not have any concerns to share about Three Cups.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider promoted continuous improvement through effective governance and oversight. Events were reviewed promptly to identify themes, learn from incidents and improve practice. Staff said they were encouraged to share feedback through meetings and supervision. One staff member said, “We are encouraged to share ideas, and managers listen and act on our feedback.”