Operations Office

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 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 vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion.

The service’s mission was to work with people to develop personalised support that would enable them to optimise their independence, mental and physical wellbeing and to achieve their outcomes. Service objectives were monitored through audits. People, staff and relatives were positive about the service. Staff told us the culture within the service was positive and they were supported when needed. A relative told us, “Overall, it is excellent. The team are fantastic. [Person] mobility has improved and general well-being has improved and generally well looked after.”

Staff had a good understanding of the ethos of the service and were clear about their responsibilities. They understood their roles and told us they were supported by the management team.

The management team operated an ‘open door’ policy where people, relatives and staff could speak to them at any time to ensure there was an open culture where concerns can be raised and acted upon.

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

The management knew people well and were committed in improving the service to ensure people received high quality care.

Records showed the service had received compliments from relatives on care provided. Comment included, ‘[Person] has continued to improve since [person] has moved. Supporting all [person] needs. [Person] is becoming more independent and health has improved. [Person] is very happy.’

Staff meetings were held regularly by the management team. The agenda included staff welfare, communication, people’s support needs and training. Management also gave staff opportunities to provide feedback on the service and acknowledged staff for the care they provide to people.

Staff were positive about the registered manager. A staff member told us, “They [management] are very good, very helpful. Always checking up on us.”

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

A whistleblowing policy was in place that included details on how to raise concerns both internally and externally, which allowed staff freedom to speak up. Staff feedback was also sought as part of supervisions and staff meeting.

Staff knew how to use the whistleblowing policy and understood their role and responsibilities of reporting concerns and knew who to go to if they needed to.

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.

An equality and diversity policy was in place and staff had been trained in this area. Systems were in place for flexible working arrangements as shift plans showed staff were able to work flexibly. Staff did not have any concerns with lack of support and were very positive about the service and the management team valuing diversity.

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 our last inspection, we found robust systems were not in place to identify shortfalls and take prompt action. At this inspection, we found improvements had been made.

Records showed the provider had quality assurance systems in place to ensure regular audits were carried out. Care plan audits were completed that focused on ensuring important information on people’s support needs, risk assessments were completed and personalised. Medicine audits were completed to ensure people were given their medicines as prescribed and staff were competent to administer medicines.

Quality monitoring systems were in place. Systems were in place to attain feedback from people, relatives and staff through reviews, meetings and as part of staff supervisions.

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 registered manager and staff told us they worked in partnership with health and social professionals to ensure people were in the best of health at all times. Records confirmed people had access to social and health professionals to ensure they were in the best of health.

Partners we sought feedback from did not raise concerns about the service and provided positive feedback.

A professional told us, ‘[Person] is now receiving excellent care. Since their move, there have been no safety concerns. Peak Value (provider name) has supported them consistently and provided outstanding service. I highly recommend Peak Value for the exceptional work they are doing. I am proud of the support and care they continue to offer.'

Systems were in place for learning and improvement. Improvements had been made since our last assessment with concerns relating to training, need for consent and quality assurance being addressed. An action plan was in place and the service worked on this to ensure improvements were made and sustained following the last inspection.

There were a range of monitoring and audit tools to assess and monitor the delivery of care and support to people.

The service had systems in place for learning and improvements with feedback being sought from, people, relatives and staff to ensure there was a culture of continuous improvement.