Voyage (DCA) Doncaster

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• 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 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 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. The provider had a consistent approach to supporting a shared vision and culture of support which was reinforced by training and reflective practice. Regular team meeting and reviews ensured a joined-up vision and compliance with organisational values. A member of staff told us, “We are supporting some people who have come from very traumatic backgrounds. Since living at [the service] people are now going out on activities and shopping trips out for the day. We have people who have worked with staff to create time alone plans and also people who now go home to see family for dinner in the family home. [The service] is an absolutely amazing place to work.”

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 was well organised and led and managed the service effectively. There were clear management and leadership processes in place. A member of staff told us, "I am able to talk to my manager at all times and I feel comfortable to bring forward any ideas I have. I do [feel valued and listened to]." Another member of staff said, “The [registered] manager will always spend time with staff and provides support for any changes made in the service so we can understand changes. [The registered manager] will give staff opportunities to take lead in situations and also gives us keyworker responsibilities.” A family member told us, “[The registered manager] is lovely. I get on well with them. They used to be a carer there so they know the job. [The registered manager] involves me in [person’s] care and lets me know what’s going on. I can call [the service] at any time and they will talk to me. I would recommend this service to others. It’s kept [person] safe. They have come on so much. I am right pleased with them all. [Person] has come a long way.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistleblowing policy in place and there were posters displayed giving details about how people could speak up if they had concerns. The provider ensured there were appropriate opportunities for staff to speak up. Staff had access to an on-call system, team meetings and supervision sessions. It was evident staff had good relationships with one another and with their line manager.

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 fair and inclusive culture which promoted equality of opportunity and anti-discriminatory practices. The service ensured equality, diversity, and inclusion was central in their recruitment. We observed staff from various ethnic and cultural backgrounds who worked for the service. Appraisals and supervision sessions for staff ensured they received support they needed from an inclusive employer.

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. The provider had clear systems and processes in place to review the quality and performance management of the service. The provider carried out regular reviews and compliance visits. The registered manager completed audits and reviews to monitor the quality and effectiveness of the service. The systems ensured there was continuous improvement in the service. 

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 provider shared information with local and care professionals appropriately. For example, incidents, accidents were reported to the local authority safeguarding team and to CQC. The registered manager attended meetings with the local authority to discuss concerns, get feedback and share ideas about the service. The provider had good links with local health professionals and information was shared in multi-disciplinary review meetings about people’s assessed support needs.

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. The registered manager was continually looking at ways to improve the service by learning lessons and sharing good practice. People were involved in their care and the provider listened to new ideas about how care could be improved and developed in line with people's changing needs.