Chiltern Support and Housing

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 requires improvement. 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, 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. A member of staff told us there was a focus on team effort and there was, “Increased person-centred care and everyone is competent to play their role in this 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. A member of staff told us the leaders empowered them which made them, “confident in what we are doing and how we support the people.” The provider held staff meetings.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a freedom to speak up and whistleblowing policy and procedure. A member of staff told us, “I do feel supported and I feel safe to speak out on anything that might be oppressing me or the people I support.”

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. We received mostly positive feedback from staff. A member of staff told us, “The service is flexible and will make adjustments for flexible working requests.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Audits were not always effective in identifying issues as they did not identify the concerns CQC identified during this inspection. We found improvements were required in the provider’s records which had not been identified through audits. For example, care records included an emergency information sheet and a hospital passport, however, we identified inconsistent information regarding medicines between these records. The audit of the daily notes did not identify if consent was obtained before delivering care and that undignified language had been recorded when referring to personal care being delivered. The provider did not fully understand their responsibility in relation to completing mental capacity assessments and best interest decisions. The audits did not identify risk assessments had been fully completed, for example, in relation to emollient creams being a fire risk nor correct information being recorded within people’s medicine records. The provider did not conduct audits of their recruitment files to ensure safe recruitment. The provider had not established effective systems to enable them to ensure compliance with their legal obligations and the regulations.

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. There was regular engagement with people and their representatives and a focus on supporting people to thrive, develop skills and live the life they chose.

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. A member of staff told us, “We are always involved to have a debrief when an incident occurs and say our ideas and thoughts. We then agree a better way to do things.”