ESPA Agency

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 good. At this assessment 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 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. A relative told us, “From the top down the organisation has good values. I have had no bad experiences at all.”

The provider encouraged people and relatives to give feedback and make suggestions to help drive improvement and ensure the service continued to meet people’s needs.

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 provider consulted with key stakeholders through a variety of methods, to capture their views and make inclusive decisions. Staff felt enabled to make suggestions and share views about the service and felt listened to. A staff member told us, “I feel able to raise suggestions and concerns with management, and they do listen. I usually receive feedback on actions taken in response to my concerns.”

A relative spoke positively about the service and management. They said, “These guys are a good team, are very caring and management understand the issues.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a complaints procedure in place that was accessible to people and relatives, and available in different formats.

People and relatives felt staff and management were approachable, enabling them to raise concerns if necessary. A person told us, “If there were any issues I would speak to my key worker and [Staff member] is always helpful too. [Registered manager] and [Team Leader] are there if I need them. I (previously) raised a complaint (with management) but they sorted everything out and I was happy with their actions.”

The registered manager told us, “Administrators send out the complaints procedure to all parents annually to ensure they are aware of the complaints procedure and know how to raise any concerns.” A relative told us, “[Registered Manager] and [Team Leader] are amazing and are always accessible if I have any issues or concerns. There was a small glitch about three weeks ago (involving a support worker’s conduct). I mentioned it to [Team Leader] and it was cleared up straightaway. [Team Leader] is very good.”

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 had appropriate policies and procedures to support staff and promote equality and diversity within the workplace. The provider made reasonable adjustments to individual working conditions, to enable staff to do their jobs and support people effectively and consistently. The registered manager told us, “We consult with our HR, and try to accommodate with changes in working hours to support the staff.”

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.

The registered manager and staff understood their roles and responsibilities. Senior staff and management monitored the quality and safety of service provision through a range of audits, to make sure they continued to deliver a high standard of care and to drive improvement.

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. A relative told us, “[The provider] pulled out all the stops so [Person] could transition back to the organisation and always remained positive. Both [Person] and I are very satisfied with the (staff) supporting them. [Team Leader] has a really good relationship with [Person] and all the other parents. I am smiling as I talk to you because it is an absolute pleasure to work with them (staff).”

Staff supported people to integrate into the community, doing things they enjoyed and that were in line with their personal interests. For example, going to restaurants and socialising with friends over a meal.

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. For example, they provided full information and support to a person entering a physical relationship with another person. They were educated in sexual health, keeping safe, taking precautions and understanding their decision to enter into a physical relationship. Staff also assessed their capacity to ensure they were able to understand and make the decision safely and lawfully.