Master Quality Health Care Services

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 our last assessment we rated this key question requires improvement. At this assessment the rating 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, engagement, and understanding challenges and the needs of people and their communities.

Staff told us they felt supported by the manager. The management team knew about people's needs and preferences, and how to support staff to deliver person-centred care. There was a positive, supportive culture where leaders and staff shared ideas for development and improvement. Comments included, "The manager is helpful and always listens to staff, we meet and discuss to share things" and "We are one team, they are all supportive I must say."

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.

The registered manageradopted an inclusive leadership style, encouraging the development of staff. Staff told us they felt valued and enjoyed working for the provider. A staff member told us, "I'm happy where I am now, I've been supported to do an NVQ 3."

Processes were in place to ensure staff met to discuss relevant aspects of their roles through regular meetings. One staff member told us, "At team meetings any problems are shared, and advice is given, and support." Staff respected the knowledge and experience of leaders and told us they were open and approachable. Comments included, "We are well informed of what is happening and it is easy to go to [the registered manager] for guidance. The registered manager has been a mental health nurse and worked with people, she comes in as an understanding person, for both practical and emotional issues as well."

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

Staff told us they felt confident to speak up and raise concerns. A whistle blowing policy was in place and staff knew where to find it. Feedback from staff included, “There is a process to support confidentiality within the organisation for staff”, “I have a platform to air my views”, “I’m given opportunity to talk and if I have any difficulties, meetings are every month" and "I can speak about any problems or challenges I'm facing at work." The provider had recently developed employee surveys to promote a speaking up culture.

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 and inclusion and employed a diverse workforce from varying backgrounds and cultures. The well-being of staff was important to the provider, and this was included as an agenda item at team meetings.

Staff told us they felt valued, supported were treated equally. A staff member told us, "Flexible working is supported, you can go for childcare, and they also provide water for keeping hydrated in summer, we are all treated as equals."

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.

Quality assurance systems and processes were in place and effective in supporting service improvement. Regular audits were undertaken. Where concerns were identified appropriate action was taken. Spot checks were regularly carried out to oversee staff performance and to check the quality of care and people's experiences. Appropriate policies and procedures were in place to support effective governance.

The management team understood their responsibilities to record safety incidents and concerns, and they reported these internally and externally.

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 demonstrated effective partnership working with health and social care professionals. Regular involvement from the district nurse, and referrals to speech and language teams were recorded in people’s care plans. Joint working with the local authority had supported improvements to record keeping and auditing within the service. One staff member told us about the improvements made to record keeping and said: "We are getting support from the council since the last inspection. It makes work easier for the staff when everything is here."

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.

Systems were in place to promote continuous learning and service improvement. Lessons learnt were appropriately shared with staff to support this.