Northbourne

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 outstanding. 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 71 (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 and culture for how care should be delivered, based on openness, respect and fairness. Leaders were clear about how they expected care to be delivered and about the importance of learning from mistakes. Following a period of instability, leaders focused on improving consistency and standards across the service. They were open about areas that needed to improve and encouraged reflection and discussion rather than blame. A staff member told us, “There’s a passion to care and the management team are clear about improving things.”

The provider had inclusive leaders at different levels who understood the service and the people they supported. Leaders had the skills, knowledge and experience needed to lead effectively and acted with integrity, openness and honesty. They were visible during the inspection and showed a clear understanding of the service’s risks and priorities for improvement. Leadership arrangements, including regional oversight, helped maintain continuity and ensured leaders were accessible and responsive when concerns were raised. A relative told us, “Team leaders are very approachable and keep us informed.”

The provider fostered a positive and open culture where people, relatives and staff felt able to speak up and were confident their views would be listened to. Relatives knew how to share feedback or raise concerns and reported that leaders were accessible and responsive. Issues raised were acknowledged and acted upon, demonstrating that feedback was valued and used to support improvement. A staff member told us, “There is an open door policy, and I feel comfortable raising concerns.”

The provider valued diversity within its workforce and worked towards creating an inclusive and fair culture. Systems were in place to support equality, diversity and inclusion, including training, recruitment processes and reasonable adjustments for staff. Leaders demonstrated an understanding of equality and human rights responsibilities and promoted inclusive practice across the service. A staff member told us, “I’m treated fairly and supported by the organisation.”

The provider did not always have effective governance arrangements to identify, manage or mitigate risks in a timely way, particularly in relation to environmental safety, fire safety and night time staffing capacity. Assurance systems had not consistently identified or resolved these risks prior to inspection.

In response to concerns identified during the inspection, leaders acted promptly and proportionately. They escalated risks to specialist contractors, implemented safety measures, increased staffing levels and strengthened regional oversight.

However, not all routine checks and oversight arrangements were fully embedded, and further work was needed to strengthen quality assurance and oversight of quality and safety. A relative told us, “Things have improved recently, but change has taken time and some issues should have been addressed sooner.”

The provider understood their responsibility to collaborate and work in partnership so that services were coordinated and responsive to people’s needs. The service worked effectively with a range of external professionals, including GPs, community nurses, mental health services and specialist teams. Leaders engaged with commissioners and partners to manage risk and support positive outcomes for people. Information was shared appropriately and contributed to positive experiences and outcomes. A relative told us, “GPs and other professionals are involved when needed and staff follow things up.”

The provider focused on continuous learning and improvement across the service. Leaders used feedback, incidents, complaints, audits and inspection findings to identify learning and drive improvement. There was evidence that learning led to positive change, including improvements to staffing arrangements, environmental safety, care planning and training. Leaders reflected openly on practice and encouraged learning rather than blame. A staff member told us, “When things go wrong, learning is shared and processes are improved.”