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.

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 my manager is always there with an open door for any suggestions or concerns I need to bring to them and always feel I am listened to.”

Relatives spoke positively about the registered manager. A relative said, “[Registered manager] is very good and leads the service well.”

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, “Staff do help me if I need things. I can always speak to them. If there is something wrong, I know who to speak to.”

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 said, “[Management] are accessible and if I have any concerns I will speak to [Team Leader] or [Registered Manager]. If I contact them, they get back to me quickly.”

People had access to appropriate advocacy services such as Independent Mental Capacity Advocates (IMCA), to support with decision-making and ensure their voices were heard.

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. Staff liaised with organisations in the community, to support people to achieve their goals. For example, arranging for a person to gain work experience working on a farm.

When discussing a person’s transition into the service, a health professional said, “[Registered manager] was clear and assertive, using her experience to explain what the support may look like for [Person], citing examples from other (success stories). [Registered manager] was proactive in designing the transition schedule and attended transition meetings as well as meetings outside of that to address care package questions.[Registered manager] was vital to the success of the transition, asking the questions that required asking so that any barriers to discharge could be resolved.”

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. A health professional said, “There were a core staff team that had worked at the accommodation for a long period of time who were able to articulate the process applying strategies to the client group. Staff would drop practical strategies and techniques into conversations that were being used to support [Person]. An example being they asked a person to count to two if they were staring too long at people in the community - a simple yet socially vital tool.”