United Response - 66 & 66a Lemsford Road

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 inadequate. At this assessment the rating has changed to requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 62 (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 vision and values of the service were clear and promoted people’s rights, choices and independence. This was echoed in staff feedback.

The manager shared there is an improvement plan to help improve the culture within the service. This included introducing observational supervisions to help build on the values and ensure best practise approaches are embedded.

Staff attended regular team meetings where information was shared, and important issues were discussed, helping to maintain a consistent and shared approach to people’s care and support.

A structured induction process was in place, so newstaff were well prepared and understood the culture and standards expected within the service. The manager had a hands-on approach and led by example. HR systems were in place to address performance issues where needed.

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 manager was new to the post and has applied to CQC for registration. The manager has previously been a registered manager and has a history of managing services for people with a learning disability and autistic people.

Despite being new to the service, the manager was well informed about the service, its history, the staff team and the needs of the people being supported. The manager demonstrated they are reviewing incidents holistically looking for themes and trends and new areas of learning.

One staff member said, “If I give feedback to the manager, they will always act on it.”

The manager was supported on the day of the assessment by a senior member of the leadership team who demonstrated a passion for wanting to drive improvements. Staff spoke with pride about United Response and shared it was important to them to improve.

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

The provider has a range of communication tools to help people communicate and this included an accessible complaint form.

Staff told us they can speak openly and the managers will listen. Staff new the names of senior leaders at regional levels and said they would report concerns to them if needed.

We saw whistleblowing information displayed 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.

The provider had a diverse staff team with different backgrounds and values. The provider shared they have identified the need to share knowledge and experiences of different beliefs and values to ensure things that are important to people are valued and not overlooked.

The provider had systems of accountability and governance, which they used to manage and deliver good quality, sustainable care, treatment and support. However, the provider had not always identified the wider issues within the service.

Although the provider carried out audits on a range of critical areas, including medicines, IPC, the environment and care planning they were not always fully effective and failed to identify the concerns highlighted in this report. For example, first floor windows without restrictors and medicines not being stored correctly and poor IPC. Reviews of care plans and documents failed to identify the important information missing in people’s personal health plans.

Bathrooms were unclean and in poor condition.

The provider demonstrated through taking immediate action to address our concerns that they were open to feedback, responsive and wanted to be compliant.

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 provider demonstrated they worked in partnership with social workers, GPs, nurses and other agencies such as day services.

A stakeholder said, “There have been multiple changes to the team over the last year, but they do have some really committed staff who seem very passionate about getting the service delivery right for people.”

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.

Staff at all levels were encouraged to think creatively, contribute ideas, and seek out opportunities for positive change. By promoting open dialogue and the sharing of best practices, the provider ensured learning was embedded into daily routines and strategic planning. This commitment to ongoing development meant that the organisation remained responsive to people’s changing needs and their quality of life.

Staff spoke about personal development and learning from incidents.

We saw evidence of a pictorial lesson learnt review aimed at improving communication strategies for one person.