Royal Mencap Society - Central Hampshire

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.

At our last assessment the service was in breach of the legal regulations in relation to notifications of other incidents and good governance. At this assessment the service had improved sufficiently and is no longer in breach of these regulations.

This service scored 71 (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 service understood the challenges and needs of people being supported. The care and support people received reflected the provider’s values and objectives as set out in their statement of purpose. With staff commenting most about the service being “kind”. The provider promoted a positive, open culture and inclusive ethos. However, they had not become complacent in this and worked to resolve any negative culture which arose.

The culture and direction of the service was driven by its staff who had the best interests of the people supported at the centre of all they did. This was confirmed through our discussions with people and staff.

The provider used team meetings to ensure staff were aware of their values and what was important. Staff told us they were happy with the company. Staff told us there was a culture of collaboration, where people and staff were listened to and communicated with. This demonstrated a pro-active approach to engagement with staff to improve the culture at the service.

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.

Staff told us leaders were open and honest, and they were able to contact them when needed. Senior staff were receiving appropriate training and ongoing development programmes relevant to their roles. The registered manager had a level 4 manager’s award and many years’ experience in adult social care working with people with a learning disability and autistic people. The registered manager was very positive about the provider and the support they had from their line manager. This was reflected by the staff we spoke with. The registered manager knew what needed to be referred to safeguarding and the notifications needed to be made to CQC.

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

Staff told us they felt comfortable speaking up and raising issues to senior staff as the service managers were available to support them. Staff also told us the registered manager was available if the service manager wasn’t. The provider had a whistleblowing policy in place including who to contact inside and outside of the service when appropriate. The provider demonstrated an open approach in their engagement with staff and acted to address their concerns when known. Staff knew who and what to report both inside and outside of the service and felt able to do so to protect the people they supported.

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.

There was additional support for staff new to care during induction and shadowing. Staff told us they felt well supported by the provider.

There were policies in place for equality and diversity which staff had access to. The provider had employed a diverse workforce, some through the government sponsorship scheme. There was ongoing support by local service managers for staff to resolve any issues identified through observation and supervision.

The provider had clear responsibilities, roles, systems of accountability and good governance. However, some policies and records relating to the service needed review to ensure leaders had sufficient guidance to monitor quality and risk in all aspects of the service. The registered manager told us regular checks and audits were completed to monitor quality and risk in the service. These included audits relating to finance, medicines, environment, and observing staff practice. There were also regular reviews of people’s care. However, it was not always clear how often these took place or what other areas were audited. For example, audits had not identified the concerns we found in relation to recruitment and staff training records and policies.

The provider used feedback from people, relatives, staff and partners to learn from and improve the service. There was evidence at a provider level of trend analysis of incidents and work being done to reduce recurrence. Action plans had been produced from these. There were improvement plans in place for the individual households showing what action was being taken to address any shortfalls identified by the registered manager and provider.

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 worked with key stakeholders, including commissioners, and health professionals. For example, the provider worked closely with social workers for reviews of care, deputies for people’s finances and advocates for the best outcome for the people they support. Staff told us if they raised any concerns their manager would follow up with professionals to get the support needed for people. Staff also said they had good interaction with professionals when they visited people. This helped to promote positive outcomes for people using the service.

The provider was motivated to work towards continuous learning and improvement across the organisation and local system.

The registered manager told us newly introduced governance systems provided more flexibility enabling them to independently review quality when they wanted or needed to. At this assessment the service had improved sufficiently and is no longer in breach of regulations.

Staff we spoke with said there was continuous learning at team meetings and how important feedback from relatives was to improving the service.

The provider was open to feedback during the inspection and started making improvements for example, reviewing their recruitment policy.