Ballards Ash

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.

Staff were provided with information on the provider values at induction and at various training events, supervisions, team meetings and handovers. The provider was clear about the standards of care expected and took action if needed to address any shortfalls. There was a clear line management structure at the service, and staff knew where to go with any concerns or ideas for improvement. One member of staff said, “I like to give my ideas, and I get the sense they [leaders] are listening to me. It is good to know your thoughts are valued.”

Staff we spoke with all enjoyed their work and understood the principles of person-centred care. One member of staff said, “I enjoy the work. I love to learn and you can learn from people. Disability does not mean inability and people are capable of doing things on their own.”

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.

There was a new manager in post who was applying to be registered. They were being supported by the current registered manager who had been at the service as a temporary interim arrangement. Feedback about the management from staff was positive. Staff felt able to approach all leaders including visitors from the provider central support teams. Staff said having changes in management had been unsettling, however, they were pleased to have a new permanent manager. One member of staff said, “[Manager] knows what they are doing and we know what [they] want. I like the sound of their ideas.”

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

The provider had whistleblowing policies which were available at the service and on electronic devices. Staff said they knew how to speak up and felt confident the provider would take appropriate action. However, if action was not taken staff knew where to report any concerns outside of the service.

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.

The provider had equality, diversity and inclusion policies and procedures which were readily accessible to staff. Training was provided to help staff with awareness of inclusive ways of working. There were staff working at the service from various cultures. Staff said everyone was welcoming and worked in an inclusive way. If staff needed time to engage in activity relative to their culture, this was organised by leaders.

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.

Governance systems were effective in monitoring quality and safety and driving improvements. Since the last assessment the provider had increased quality audits and further developed governance systems to identify shortfalls. Areas of the service were being assessed by different staff from across the organisation. This helped ensure a wide range of areas for improvement were identified. For example, audits were being completed by staff and management at the service, a regional director and members of the provider quality team. Actions were added to service improvement plans and reviews and monitored until completed.

Leaders were aware of the requirements to notify CQC of any incidents and events and to have their CQC rating displayed at the service and on the provider website.

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 in partnership with a range of professionals to help meet people’s health and wellbeing needs. Feedback from professionals was positive. They found the staff to be caring and helpful and shared information with them in a timely way.

Leaders worked with professionals from the local authority. Various teams visited the service to review people’s care or carry out their own quality checks.

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.

The provider had increased quality and safety checks at the service following our last assessment. The provider was visiting monthly but due to improvements seen reduced visits to bi-monthly. Since the last assessment the service had moved to an electronic care planning system. This had helped improve access to care plans and risk assessments and enabled the provider to increase quality checks. The provider was part of a pilot to use an increased safety function for the care planning system. This would enhance oversight and help make improvements in areas such as incidents, accidents and health and safety checks.