4 Hermitage Lane

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 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 worked in line with the provider’s values. For example, we observed staff treating people with dignity and respect and staff putting people first. There was positive culture at the service. For example, relatives felt the service was “open and transparent”.

Staff worked in line with ‘Right support, right care, right culture’. For example, people had access to the community, people were supported in line with their preferences, and were supported by staff who knew them well.

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.

Staff spoke positively about the management team. Comments included, “[Registered manager and operations manager] are great, they are always there”, “[Management] are there if you need a chat, if you have a question, it gets answered” and “They are very supportive”. Staff told us the manager supported them with providing care if needed, and we observed this during our site visit. The management team had completed training relevant to their role. Relatives spoke positively about the management team and described managers as approachable.

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

People told us they were not worried about anything, but if they were felt able to speak with staff. Staff also felt able to speak up and raise any concerns. Comments from staff included, “We have really approachable management, they are really friendly, I wouldn’t feel scared talking to them” and “I can ask the same question a thousand times”. We observed there was a suggestion box for people to use if they wanted to share feedback anonymously.

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.

Staff told us management made reasonable adjustments where needed. One staff member commented, “I had to have some time off work recently, this was really well accommodated. I really appreciated this.” Staff told us they were able to leave work for appointments.
 

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.

Management completed a range of audits to ensure compliance. This included health and safety audits, infection control audits, medication audits, and health themed audits. The operations manager also completed their own audits of the service. Staff told us they felt the service was well managed. One staff member commented, “[Management] are very detail oriented, they are very keen to check compliance stuff is all done.”

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 well with healthcare partners. For example, we saw referrals to the Speech and Language Therapy team were made where required. People had regular health appointments to ensure their health needs were met.

The service also sent out monthly newsletters with pictures of people taking part in activities. These were sent out to relatives which supported communication.

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.

Staff told us they felt there was a learning culture at the service. The provider facilitated staff to undertake further qualifications in health and social care. One staff member told us, “They give us the opportunity to progress, they support us with qualifications.” We saw learning took place following incidents, accidents and audits. The service also shared learning across other services among the organisation to improve practice.