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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 assessment, we rated this key question requires improvement. 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 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.

The registered manager operated an ‘open door’ policy where people, relatives and staff could speak to them at any time.

Staff told us the registered manager was approachable and was easy to talk to if they had any issues to discuss.

Staff had a clear understanding of what was expected of them.

The registered manager understood their legal responsibility to be open and honest when something goes wrong and had responded accordingly where the duty of candour applied. They had submitted notifications to CQC in an appropriate and timely manner in line with CQC guidelines.

The provider had inclusive leaders at all levels who understood the context in which they delivered care.

The registered manager maintained positive relationships with staff, people using the service, and their relatives. Staff said the registered manager was approachable and easy to talk to if they had any concerns, and they expressed that they enjoyed working at the service.

There was an effective communication system in place between staff and management. Relatives reported that they were kept informed about their family members’ wellbeing. A relative told us, “The staff always call me if there is anything I need to know.”

The management team had clearly defined roles and responsibilities, and they consistently demonstrated the service’s values, acting as positive role models for the rest of the staff team.

The management team were accessible and approachable to both the people, relatives and the staff team. They worked alongside staff and were involved in the delivery of care to people.

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

The service had a whistleblowing policy that provided staff with clear guidance on who to contact if they had any concerns. Whistleblowing is the act of reporting wrongdoing, misconduct, or illegal activities within an organisation.

Staff reported that the registered manager encouraged open communication and that they felt confident raising issues with management.

People using the service and their relatives told us that they would approach a member of staff or the registered manager if they had any concerns.

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 valued diversity within their workforce and fostered an inclusive, fair culture that enhanced equality and equity for all staff. Differences related to gender, race and ethnicity were recognised and respected.

The provider ensured that staff were treated fairly and equitably. For instance, support was provided for staff experiencing personal issues resulting in improved well-being.

Beyond contractual obligations, the provider created opportunities to support staff well-being, such as organising social events. Staff were also supported in observing religious celebrations and holidays.

Minutes from staff meetings demonstrated that staff were fully informed about service developments, and incidents were shared to facilitate learning. The provider encouraged an open-door policy, allowing staff to raise concerns or suggestions comfortably.

The provider had a clear equality, diversity, and human rights policy to ensure that neither staff nor people using the service were subjected to discrimination.

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.

At the last inspection, we found the provider’s quality assurance processes failed to identify issues we found at inspection; risk assessments not being holistic, gaps in staff’s employment, issues with consent, mental capacity and confidentiality.

During this assessment, we found improvements had been made around the concerns we identified at our previous inspection. Risks assessments and mental capacity assessments were comprehensive, the recruitment process was more robust, and records were being kept securely.

The provider had effective systems in place to quality assure the services provided, manage risks and drive improvement.

The management team undertook regular audits to monitor the quality of the service they provided. This included regular care plan reviews, medicines administration, staff training and health and safety checks audits. If shortfalls were identified, appropriate actions were taken, for example, asking staff to complete refresher training if they were not up to date.

The registered manager identified areas for improvement and discussed them in staff meetings.

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 service worked closely in partnership with other services and professionals across the community. This enabled them to deliver better care, support, and outcomes for the people who used the service.

The management team stayed up to date with best practices in the health and social care sector. They regularly attended meetings within this sector and actively engaged with the community, enabling people, their relatives and other professionals to contribute to the development and shaping of the service.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The provider had an inclusive and positive culture of continuous learning and improvement.There was a variety of monitoring and auditing tools were in place to check the quality of care and support being provided to people.

The provider sought feedback from people using the service, their relatives and staff, then reviewed and analysed this information to support the registered manager in identifying improvements and enhancing overall service quality. Comments from the recent completed satisfaction surveys were positive. People and their relatives felt listened to, and that their views were considered.

The provider had a system to log complaints and concerns. Records showed the details of each issue, the action taken, and the outcome.

People’s care experiences were regularly reviewed to find ways to better support them in achieving their goals.

The management team also conducted regular unannounced spot checks on staff at different times to ensure care and support were being delivered to people safely.