Inshore Support LTD - Supported Living

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 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.

The registered manager and staff were aware of the values of the organisation and spoke positively about the culture of the service. Discussions with staff demonstrated their awareness of closed cultures, and how these could develop and the action they would take. A staff member told us, “I would raise any concerns if colleagues were not working in accordance with peoples care plan, or if they were being disrespectful to people.” The registered manager told us they completed spot checks on staff to monitor care practices and records were in place to support this.

Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

People and relatives spoke positively about the management team. One person said, “I like [manager] she is nice and comes and makes sure I am okay, and staff are kind to me.” A relative told us, “All the managers and provider are approachable and friendly. I would give them and the staff a medal for the good work they do.” The management team were visible within the service and led by example to their staff team, demonstrating inclusive behaviours.

Staff knew their roles, responsibilities and how to support each other. They told us they felt supported and valued by the management team.

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

Relatives felt confident to raise and share concerns. They were confident action would be taken. Staff felt confident to report, whistle blow and raise concerns if needed. Staff spoke positively about the management team who they described as open, listened and acted upon feedback. The provider had a ‘freedom to speak up guardian’ in place and their details were shared with people and staff. This enabled concerns to be shared confidentially either in writing, face to face or via a telephone call.

The provider had systems in place to gather feedback from staff including completing surveys. This enabled staff to share any concerns confidentially if they did not have the confidence to use other methods in place. The registered manager told us they had created an open-door policy where staff were able to speak up and share their concerns at any time.

The provider valued diversity in their workforce.

Staff told us they were happy working for the provider. A staff member told us, “I love working here we all work together as a team and the management team are always there if we need them.” Another staff member said, “The management team are very accommodating to my needs and when needed I can work flexibly. The registered manager told us when they recruited new staff they tried and match staff with the needs of the people they supported in respect of age, gender, culture and language.

The provider’s governance systems were not always effective.

Although systems were in place to monitor the quality of the service some improvements were required to make these more robust. For example, an auditing tool was not in place to check the recruitment of staff. Therefore, gaps in staff employment had not been identified. The quality and detail of some records were not always consistent across the service and timely action was not always taken to ensure detailed information had been provided in relation to incidents that had occurred. The registered manager was receptive to our feedback and demonstrated their commitment to making any required improvements such as implementing an audit and completing actions plans.

The registered manager and provider were aware of the current best practice guidance right care, right support and right culture. However, we found some examples where this was not always followed. For example, where staff information was displayed in people’s homes. Once we raised this action was taken to remove these.

The registered manager was aware of the need to promptly inform CQC of any notifiable incidents in accordance with their legal responsibilities.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The provider worked in partnership with other agencies, and this ensured positive outcomes for people and improved care. Staff monitored people’s wellbeing and any emotional distress. This information was shared with healthcare professionals to support any changes to people’s support plans. Staff worked with advocates, who told us staff listened and acted upon any recommendations that were made.

Feedback received from partner agencies was positive. Agencies confirmed the provider worked with them and completed any recommended actions following quality visits that were undertaken.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The provider has systems in place to learn lessons and drive improvements. Regular incident analysis was taking place. There were monthly reviews then quarterly analysis. There was a comparison per quarter but also year on year comparison. There was detail about what may have caused distress for people and what had been tried to alleviate people’s anxiety and distress, including what had worked well. There was a significant reduction in distress and physical interventions shown for some people. The use of PRN was also analysed and compared year on year, and this showed a reduction in usage for some people.

Systems were in place to analyse learning from other areas of the business such complaints, safeguarding, recruitment practices and staff retention. Action plans were in place where it had been identified things could be improved upon and different approaches applied.