Prospect House

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 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 leadership style and approach were consistent, respected individual rights and encouraged engagement and understanding of both staff and people living at the service. This approach was delivered through the registered manager who shaped the culture at the service. Staff and relative feedback, governance checks and partner organisation information all demonstrated an improved fair and open culture of collaboration. Staff and registered manager worked well as a team.

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 registered manager knew all the people at the service well, this was supported by consistent information in care and support plans. Likewise, the registered manager knew the staff well, and their feedback was consistent; that the registered manager had the right skills and qualities to make them want to do their best. Furthermore, staff told us the registered manager was present and proactive. Staff fed back very positively that the registered manager had made a tangible difference since taking on the role and worked hard and consistently to improve all aspects of the service. Staff said that they were respected, supported and received appropriate training and development.

The registered manager adopted a very caring and efficient approach to the assessment.

Feedback from relatives demonstrated that the registered manager was approachable and communicated well with families.

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

Evidence from all sources indicated individuals and families were empowered to speak up and be heard; however, this was on an individual basis. This included notes of review meetings as well as quotes in care and support plans. Some relatives said they would like more opportunities to meet with the team as a group. Regular meetings started during the assessment period.

Staff had regular meetings plus handovers daily, so stayed informed and able to speak up. Staff were comfortable talking to us during the assessment process and reflected on improvements that had been made. No staff expressed reticence about speaking up and were aware of how to do this. Notices provided the means to access external support and advocacy for staff.

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 approach considering diversity and inclusion were built into recruitment and selection processes, as well as staff reviews, supervisions, disciplinary records and staff meeting notes. The staff team came from a diverse range of backgrounds but worked cohesively with no perceived barriers.

The provider offered a range of options for working patterns and shifts to support people’s lifestyles and needs. Staff gave us mixed feedback about shifts, with some telling us that they would like more flexibility and others that they were happy with current arrangements. All confirmed that they felt able to address this with management and had an expectation to be treated equally.

Overall, staff feedback was consistent, indicating good inclusion and fairness. The team was from a diverse range of backgrounds representative of the local area. Training and development were available to all and people mentioned having suggested additional learning to help develop their careers in the sector.

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 had worked hard with the area manager and a quality improvement colleague to improve the service in every aspect since they had taken the post. Staff feedback was positive about improvements made within the service. Relatives shared their appreciation of improvements but felt there were still things to work on.

External feedback also indicated a successful period of improvement, evidenced by consistent and effective governance.

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 had developed strong relationships with partners including a local GP service and a dental practice. Other stakeholders fed back positively about working with the service including the local authority.

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.

There were processes to ensure that learning happened when things went wrong, and from examples of good practice. Leaders encouraged reflection and collective problem-solving, including the involvement of relatives. Following incidents, actions taken and lessons learned were documented, discussed at team meetings and reported to CQC promptly using the correct methods. This was supported by and involved a quality improvement colleague and the area manager.