23 Cecil 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 good. At this assessment the rating has remained 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 79 (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 registered manager and leaders collaborated closely with people, staff, and stakeholders to help promote a positive culture. The registered manager had a clear vision for how they wanted their service to operate, to truly ensure people were at the centre of their support. Staff told us they understood how their role helped people to receive person centred care. One shared, “There is a positive, open culture within the team and management’s dedication to high standards ensures the care provided is of high quality and a strong commitment to continuous improvement and person-centred support”. This demonstrated how the whole team held a positive, compassionate approach to supporting the people who used their service.

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 registered manager and other leaders spent time delivering care and interacting with people, so there was a mutual respect between all staff. This meant communication was open and leaders were approachable if anybody had concerns. Leaders interacted with people in a compassionate way, adapting their communication style to meet the needs of the individual. This demonstrated they knew people well and people and their relatives confirmed to us they found all leaders approachable and responsive.

Supervisions and appraisals were completed on a regular basis, ‘off site’ so staff had an opportunity to talk about their development and raise any concerns they may have, in a confidential setting and without any impact on the people they supported.

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

Staff were aware of the service’s whistleblowing policy, which was easily accessible within the home. Staff were clear on how to escalate concerns both internally and externally. Staff told us they felt very well supported by the registered manager and confident that any concerns raised would be taken seriously and acted upon appropriately. Comments included, “Management is exceptionally supportive, approachable and responsive” and “There is always a clear escalation path and a reliable out of hours system, so we feel fully guided if an unexpected situation arises”.

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 group of staff who told us they felt they were included, respected and treated equally. The provider had policies and procedures for inclusion and diversity within the workforce. For example, making sure the most suitable person was chosen for the position and recognising people’s protected characteristics, and ensuring appropriate measures were in place to support these. Protected characteristics are a set of 9 characteristics that are protected by law to prevent discrimination. For example, discrimination based on age, disability, race, religion or belief, and sexuality. Staff described an environment where they felt listened to and genuinely cared for contributing to an overall very positive workplace culture.

The provider demonstrated exceptionally strong leadership, robust governance and accountability arrangements which ensured the consistent delivery of high-quality, sustainable and person-centred care. Governance arrangements were fully embedded and used effectively to monitor performance, manage risks including positive risk management, which drove continuous improvement.

Leaders described the service's long-serving and highly committed staff team as one of its greatest strengths. The continuity and stability of the workforce enabled staff to develop exceptionally trusting relationships with people and their families, resulting in a deep understanding of individual needs, preferences and aspirations and consistently positive outcomes.

The provider demonstrated exceptionally robust governance arrangements which ensured people consistently received safe, high‑quality and person‑centred care. Clear roles, responsibilities and lines of accountability were firmly established at every level. This enabled leaders to identify emerging risks early, respond proactively to changing circumstances and continually improve the quality of care provided. As a result, people consistently experienced safe, responsive and highly personalised support that achieved positive outcomes and enhanced their quality of life.

There were comprehensive checks and audits in place covering all aspects of safety, quality and experience. These were carried out regularly and used proactively to identify where improvements could be made. Leaders consistently drew on the most accurate and up‑to‑date information about risks, outcomes and service performance. Rather than using audits as a passive checklist, leaders scrutinised care trends and risks to implement innovative, preventative interventions. When areas for enhancement were identified, action plans were developed promptly and progress was monitored closely.

Information was shared securely and appropriately with healthcare partners and external professionals to ensure continuity of care and support effective decision‑making. Notifications to the CQC were submitted promptly, reflective of a transparent and accountable approach to governance.

The provider demonstrated exceptionally strong leadership, governance and accountability arrangements which ensured the consistent delivery of high-quality, sustainable and person-centred care. Leaders used findings constructively to refine practice and strengthen outcomes for people.

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.

People attended a wide range of different activities and local community and voluntary groups, and leaders maintained good relationships with these organisations. This helped to ensure communication was good and people benefited from regular activities in the community.

Relatives and professionals confirmed they were invited to participate in care reviews and were kept informed of any changes in people’s care. This approach supported open communication and effective partnership working. Leaders understood the importance and value of involving external professionals with expertise to improve people’s lives. Referrals had been made to partner agencies such as mental health teams, speech and language teams and advocacy organisations.

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.

Systems of oversight included regular health and safety audits across key areas. Audit findings were reviewed and used to develop and implement action plans to ensure sustained improvements. The provider demonstrated a clear and ongoing commitment to learning, improvement, and the delivery of good quality care.