Potensial Limited - 1 Newlands Drive

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. The service had a positive and inclusive culture that was driven by a clear set of values and a shared vision. The registered manager promoted a strong sense of purpose across the staff team, ensuring everyone understood their role in supporting people to achieve the best possible outcomes.

Staff spoke positively about the culture of the service and told us they felt valued, listened to and involved in decision-making. They were encouraged to share feedback, contribute ideas and discuss the most effective ways to support people based on their individual needs and preferences.

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. We spoke with staff and members of the management team who were passionate about their work and were committed to achieving positive outcomes for people. They described how they aimed to make a meaningful difference in people's lives and demonstrated a clear understanding of the service's values and culture. We observed these values being reflected in day-to-day practice and interactions with people.

Staff told us the registered manager was approachable, supportive and provided effective leadership. They felt confident in the registered manager's skills, knowledge and ability to lead the service and support the staff team.

People told us they knew the manager well. They said they could talk to them about anything and knew they would listen and sort out any problem they had. One relative told us that communication could be improved. The manager told us he welcomed any feedback where they can improve the service.

Throughout the assessment, the registered manager and staff engaged openly with the assessment process, demonstrated a willingness to learn and improve, and were committed to addressing areas identified for development.

he provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt confident raising concerns, sharing ideas and challenging practice where necessary. They said their views were listened to and acted upon by the management team. Policies and procedures supported staff to report concerns, including safeguarding issues, whistleblowing and discrimination. The registered manager promoted an open culture through regular team meetings, reflective discussions and their visible presence within the service. This encouraged openness, accountability and continuous improvement.

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 management team promoted an open and inclusive culture where staff felt supported to share feedback and raise concerns. Staff described leaders as approachable and supportive. The service valued diversity and fostered a respectful environment for both staff and people using the service. Arrangements were in place to support staff wellbeing, including flexible working where possible. Recruitment practices were underpinned by equality, diversity and inclusion principles, and staff were encouraged to develop their knowledge through relevant training.

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. The provider and registered manager had a range of audit and quality assurance processes in place to monitor the safety and quality of the service. However, these systems were not always effective in ensuring identified issues were addressed promptly or sustained improvements were achieved. For example, environmental audits had highlighted areas requiring refurbishment and repair, but action had not always been taken within appropriate timescales. This meant known concerns remained unresolved for longer than expected. Improvements were required to strengthen governance arrangements, to ensure greater provider oversight. The provider needs to ensure that identified issues are addressed in a timely manner. This will result in consistent and sustainable improvements for people using the service.

Medicines management was subject to regular oversight and monitoring, with people receiving routine medicines reviews to ensure their treatment remained safe and appropriate. Staffing arrangements were planned around people's individual needs, helping to ensure they received consistent and person-centred support.

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 registered manager recognised the value of effective partnership working and maintained positive relationships with external professionals and agencies. They worked collaboratively with safeguarding teams when investigating incidents and concerns and engaged with healthcare professionals and community services to help ensure people received coordinated and effective care.

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 demonstrated a strong commitment to learning, improvement and innovation and actively promoted a culture of continuous development across the service. Staff had access to a comprehensive programme of training, regular supervision and competency assessments, which helped ensure they had the skills, knowledge and confidence to meet people's needs effectively.

Learning from incidents, feedback and quality monitoring activities was used to inform practice and drive improvements. Staff told us they felt well supported in their roles and were encouraged to reflect on their practice and identify opportunities for development.

The service had a range of up-to-date policies, procedures and best practice guidance available to staff. These were regularly reviewed to reflect changes in legislation and national guidance. Staff told us they could easily access the information they needed to support safe and effective care.