Headzpace Therapeutic Care

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

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 Inadequate. At this assessment the rating has changed to 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 71 (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 promoted a shared vision, strategy and culture based on transparency, equality, diversity, inclusion and respect for human rights. There was a clear focus on understanding the needs of people and supporting them to achieve positive outcomes.

The provider’s vision was to support people with complex needs, including those with a learning disability and/or autism, to live fulfilling lives where their rights were upheld and they were treated equally. Records demonstrated care was delivered in line with these values. Staff spoke positively about the culture within the service. One staff member told us, “It is a positive and supportive environment. Staff work well together despite challenges, communication is good, and the management system helps everyone focus on delivering high-quality care. The atmosphere is friendly and respectful.” This meant people received care in a respectful, inclusive environment where their rights and individuality were valued.

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.

Management changes had taken place since our last visit, and the records completed demonstrated that managers had the necessary skills, knowledge and experience to carry out their roles effectively. For example, audits undertaken had identified concerns, risks and areas requiring improvement. All staff in management roles had completed or were enrolled on health and social care management qualifications funded by the provider to further develop their knowledge and skills. Managers at all levels were compassionate and committed to supporting people and demonstrated a better understanding of best practice models of care for autistic people and individuals with a learning disability. One staff member told us, “The management team is approachable and supportive. They communicate clearly, lead by example, provide guidance when needed, and encourage teamwork.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. A new, detailed Freedom to Speak Up policy had been introduced since our last visit. This policy provided staff with clear guidance on how to raise concerns and who to contact, including external contacts where needed. Staff told us they felt able to speak up and raise concerns. One staff member told us, “I understand the whistleblowing policy and know how to report concerns both internally and externally if required. Any concerns raised would be investigated in line with organisational procedures to ensure the safety and wellbeing of the people we support.”

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.

At the time of this assessment, there was no CQC-registered manager in post; however, an application had been submitted. Although the provider had clearly defined roles, responsibilities, and systems of accountability in place, the service continued to deliver care to children in a manner that met the definition of a children’s home under the Care Standards Act 2000.

As a result, the service fell outside the scope of regulation under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Consequently, it was operating as an unregistered service and should have been registered with the Office for Standards in Education, Children’s Services and Skills (Ofsted). Prior to this assessment, the provider had been working with relevant stakeholders and had submitted applications to both the CQC for a care home registration and to Ofsted.

Effective governance arrangements were in place These were used to manage and deliver good quality. The provider acted on the best available information relating to risk, performance and outcomes. The revised management structure was effective and provided appropriate oversight of the service. There were governance systems and processes in place, including a range of monthly audits. These audits demonstrated that concerns were identified and addressed in a timely manner. Where required, the provider had reported incidents to the CQC. However, the provider had not fully embedded their safeguarding policy to ensure that all incidents meeting safeguarding thresholds were reported to the local authority safeguarding team.

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.

Effective systems and processes were in place to support joint working with other professionals, as reported throughout this report. Weekly reports were shared with local authority and health professionals to maintain oversight and communication. People were also supported to access a range of community resources and opportunities, promoting inclusion and independence.

The provider had systems and processes in place to support learning, improvement and innovation and to drive good outcomes for people.

New external policies and governance systems had been purchased to support learning and improvement since out last visit. A programme of regular audits and governance reviews had been completed, which identified concerns, risks and areas for improvement. Evidence showed these were acted upon, resulting in improvements to the quality and safety of the service. Since our last visit, changes to the management structure had strengthened leadership and oversight. Managers demonstrated the skills, knowledge and experience required for their roles, and were supported through ongoing professional development, including enrolment on health and social care management qualifications. This promoted continuous learning and the development of best practice. Significant improvements have been made since our last visit which has demonstrated a learning and improvement processes have been effective.