Coalway Lane

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. At the last inspection we rated this key question good. At this inspection the rating has remained 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 82 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities. Since the last inspection the executive team had changed, as had the name of the provider and they with the management team had reviewed all aspects of the service. They had identified what enhancements could be made to support staff to tailor and deliver person-centred care. Staff described how the management team had helped them reflect on their practice and take action to make positive changes. We observed staff consistently worked in a positive manner with individuals, used least restrictive practice and actively promoted people’s well-being.

The provider had exceptionally 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 always did so with integrity, openness and honesty. The provider had recently won an inclusive culture award. The senior executive team, senior management team and trustees regularly visited the service to gain people’s views and suggestions for improvement. They were always working toward providing the best possible support for people experiencing mental health difficulties. We found their empathetic, caring and person-centred approach had filtered down and influenced the manner staff worked with people. The senior management team were very responsive to suggestions and would rapidly implement them.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The Trustees were active members of the team and took steps to ensure they clearly understood the services and the impact these had on people’s lives. The senior management team and management team wanted to operate a positive culture where people felt they could speak up and their voices will be heard. Also an environment where staff felt able to raise any issues and be confident these would be addressed. They actively promoted Freedom to Speak Up guardians and champions and really valued all the feedback they received. The people’s team consistently promoted access to guardians and encouraged staff to raise any matters. There work had led to more staff feeling able to raise issues with them and managers. People and relatives told us they felt confident to raise concerns with the management team and these would be listened to and acted upon. Overall staff felt their views and suggestions were actively taken on board. A staff member said, “We do have regular debriefs which identify issues with the service and our residents, I feel that our views are listened too and taken on board.”

The provider and management team valued diversity in their workforce and ensured they followed best practices guidance. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. The provider had completed the diversity in health and care partners programme, which had aided a better understanding of how to promote inclusion. The senior leadership team actively shared this learning with the service.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The Quality and Safety team had designed systems that readily assisted them and the staff 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. They constantly reviewed these systems and were continuously looking to see where enhancements could be made. Routine service reviews were completed, and these had been nuanced to suit each location. Both senior managers and trustees took part in these reviews and completed listening exercises with people who used the service. These reviews produced meaningful improvements which were based on the views of people who used the service, their relatives and friends as well as staff. They also produced deep dive tools and considered closely incidents and events to determine where lessons could be learnt. Recently this had involved a full analysis of the way staff managed medicine administration and the audit tools they had produced on the back of this had assisted staff to understand where improvements could be made.

The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement. People reported they found the staff closely tailored the work to individual’s needs and had supported them to experience positive outcomes. The staff had formed a good working relationship with the crisis team, hospital staff and the local GPs. A professional said, “The team are very responsive and always let me know if there have been any changes. They are always flexible in their approach and will adapt when needed to meet people’s needs.”

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. There was a process in place for staff to ensure continuous improvement, through innovation and learning, was achieved. They had recently looked at CQC requirements and the staff team had completed a comprehensive piece of work determining how the service met the single assessment framework. Staff found this exercise greatly benefited them, as they could see what was expected as best practice and how they could achieve this. Staff were actively encouraged to work with people in ways which aimed to improve outcomes for them and allow each individual to experience a good quality of life. The provider worked with local universities to research mental health difficulties and how support could be improved. The registered manager ensured staff were supported to keep up to date with developments in best practice. A staff member said, “We are always working to make sure the service provides a high standard of care. The managers have showed us a lot of things to help improve how we work with people as well as provided a wide range of training.”