Sursum Limited Bramley 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.

At the last inspection we identified shortfalls in staff understanding of the provider’s values and vision. At this inspection we found this had improved. For example, the registered manager now held meetings with staff to discuss the provider’s values and how they could be implemented. The registered manager said staff morale had been low at the time of the last inspection, but this had started to improve. Staff now understood the provider’s values statement and told us the team worked well together. Staff said the registered manager displayed the provider’s values in the way they worked.

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.

At the last inspection we identified shortfalls in the leadership of the service. At this inspection we found this had improved. Since the last inspection the manager had successfully registered with the Care Quality Commission and a new deputy manager had been recruited. The registered manager was working towards their level 5 management qualification. People told us they knew who the registered manager was and were confident they would resolve any problems raised with them. People felt the service was well managed. Staff told us the registered manager was open and approachable, and said they had made a lot of improvements to the service since they had been in post. Staff said the registered manager was very clear about improvements that were needed, and was supportive in helping them learn and develop.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

At the last inspection we identified shortfalls in the governance systems in the service. At this inspection we found this had improved. For example, the provider had implemented a new governance system, which included a schedule of audits and feedback from people about how the service was operating. Examples included monitoring and reviewing falls, infections and wounds, using nationally recognised analysis tools. The registered manager used the outcome of these audits to develop clear action plans to address any shortfalls that were identified. The action plans included named staff responsible for taking the action and a timescale for completion. The plans were regularly reviewed with the directors to ensure actions had been completed. Records demonstrated this approach had resulted in a reduction in falls and infections in the service.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.