24 Hythe Avenue

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. This is the first assessment for this newly registered service. This key question has been rated 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 64 (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. There was a positive culture at the service. This positive culture related to people, the provider and staff team. All staff were committed to developing the service for people, to improve their quality of life and their outcomes. Staff worked together with people to ensure the support being planned reflected the wishes and needs of people.

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 provider supported staff to develop the knowledge and skills to support people who used the service. Staff told us they received an induction which was signed off by the provider when this had been completed. They also spent time shadowing more experienced staff which enabled them to get to know people and the service. One staff member said, “We are very much supported, we are constantly checked up on to see how we are getting on and if we are ok.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff understood the whistle-blowing policy and told us how they would report any concerns. They also told us how they would raise concerns outside the organisation if they were concerned appropriate action was not being taken. Staff told us they could always contact and speak with the provider even when they were not at work. Staff told us they were confident any issues raised would be addressed.

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. However, improvements were needed to ensure consistency of information is available.

There were policies and procedures to support staff and to ensure they were happy at work. Staff meetings took place where staff were able to discuss any issues, feel involved and listened to. However, these had not been recorded. During the inspection, the provider told us that meetings were now recorded. Staff received supervision and the provider told us they observed staff to ensure they were providing the support people required appropriately. However, these observations had not been recorded. We identified this as an area to improve and develop.

Staff told us they were all part of a good team that involved and supported each other. They told us they were able to discuss issues with the provider at any time and receive the support they required. Surveys were sent out to staff during the inspection and staff feedback was positive.

Improvements were needed to aspects of governance to ensure there was an effective audit system and people’s records fully reflected the support they needed and received. The provider and staff knew people really well, they understood their support needs. Staff were able to tell us about the support people needed and received each day. They understood the importance of consistent support that was each person’s choice. However, people’s care plans did not always include the detailed information that staff may require. Daily records did not include all the information about the support people had received. People were able to communicate their own needs and staff knew people well. This helped to mitigate the risks of harm. There was an audit system however, this had not identified the shortfalls we found in relation to record keeping and medicines. We discussed this with the provider as an area to improve and develop.

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. Although we did not receive any feedback from partner organisations the provider and staff gave us examples of positive working relationships they had developed. This included the GP, mental health teams and emergency services. People were independent with their health care; therefore, staff were only involved if people’s healthcare if they wished them to be. However, the provider had identified themselves to the external services to ensure they were aware of support available to people.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. However, improvements were needed to ensure developments were fully embedded into daily practice. The provider demonstrated they were focussed on improving and developing the service. During the inspection we identified areas that needed to be improved and developed. The provider immediately took these findings on board and sought out ways to make improvements. This included asking for feedback by sending out surveys. They responded to the issue of practical training by identifying how this could be addressed. These improvements need to be fully implemented and embedded into daily practice. Following any concerns, complaints or safeguarding’s the provider would share (as far as able) details with the staff. This included where any areas for improvement had been identified and actions being taken to address these. Areas of good practice were also shared with the team for encouragement.