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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

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 inspection we rated this key question requires improvement. At this inspection the rating has remained 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.The service was in breach of legal regulation in relation to governance.

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 demonstrated a commitment to developing a shared vision, strategy, and culture across the service. The provider identified that not all staff had previously aligned with the service’s values, and steps had been taken to address this. One staff member reported noticeable improvements, including more frequent staff meetings and supervision sessions, as well as increased support in understanding and using the organisation’s systems and processes. Leaders described how the service’s vision and values are embedded throughout the recruitment and staffing processes, from values-based interview questions to ongoing discussions during team meetings and supervisions. The leadership team also demonstrated awareness of the risks associated with closed cultures. We saw evidence that these risks were actively discussed in team meetings, and leaders confirmed that the organisation’s auditor had conducted a review to assess for any signs of a closed culture within the service.

At the time of the inspection a registered manager was not in place. However, the provider had made sure there was appropriate management oversight of the service and had successfully recruited a new manager who intended to apply to the CQC to become a registered manager. during the inspection process.

Staff spoke positively about the current leadership arrangements. One staff member confirmed they were supported by leaders. The staff member said, “yes, mainly changes have been managerial, so it’s been a bit different… great leadership, great support for the staff team, lots of new ways going forwards…” Another staff member shared, “I am a big fan of the management, they certainly lead by example.”

Leaders described their approach as compassionate and supportive. One leader stated, “I lead by example; there is nothing I would ask staff to do that I wouldn’t do myself. The area manager confirmed that plans were in place to ensure the newly appointed registered manager receives appropriate support to fully understand and carry out their role effectively.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. We saw policies and procedures were in place to support both people using the service and staff in raising concerns or sharing their views. One staff member said, “We are always encouraged to speak up, we have an open-door policy within the home… if you wanted to raise an issue or have a different point of view, that is welcome as well.”

We saw the provider actively sought feedback from stakeholders and used this to inform improvements. For example, in response to feedback, an “employee of the month” initiative was introduced to recognise and celebrate staff contributions.

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. Policies and procedures were in place to support staff in their role. The management team made reasonable adjustments to help staff carry out their roles well. Staff felt supported and told us they were treated fairly.

The provider had not established effective governance and management oversight. Regulatory breaches had continued in relation to safe care and governance. The provider’s audits and checks did not always identify and drive improvements and assess the quality of the service. For example, the inconsistencies found in information about how people were supported, risk management and medicines management. The provider had also failed to notify CQC of some incidents. This put people at risk because it limited CQC oversight of the service and delayed potential interventions to prevent harm. Once this omission had been identified by the provider, they had taken action to notify CQC and other relevant stakeholders of incidents.

The provider had started to take actions to address some of the concerns identified through their own management audits and during our inspection including updating care plan and risk assessment information, however it was too early to determine whether these improvements had been fully embedded.

The provider was actively working to strengthen partnership and collaborative working, with the aim of ensuring the service worked seamlessly for the benefit of people. There was a clear commitment to sharing information and learning with external partners to support continuous improvement. The provider demonstrated an understanding of the importance of sharing relevant information with other agencies and people’s family. Steps had been taken to embed this practice into the service’s processes. An external partner reported a positive experience working with the service. The provider was described as proactive in making referrals, implementing recommended changes for people and completing required monitoring forms.

The provider had not consistently prioritised continuous learning, innovation and improvement across the organisation and local system. They had not always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. For example, the service had not consistently been recognising and reporting safeguarding incidents. However, these shortfalls had been recognised by the provider and the provider had begun implementing processes to address them. At the time of the inspection, it was too early to assess whether these changes had been fully embedded into practice.There were systems to regularly seek feedback from the people who use the service, their relatives and professionals. Staff were actively involved in team meetings and encouraged to share their ideas for service improvement.