Southwold House

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. The provider and manager was working with staff to develop a culture that enabled people to focus on enjoying their lives. People were supported to take part in activities that they enjoyed doing and staff were encouraged to facilitate this. The manager had provided additional training and role modelling to staff on ways they can enable people to enjoy the activities they chose to do. This included positive risk taking to enable support that was person centred to give people more autonomy and empowerment over their daily lives. Closed cultures and restrictive practices were discussed with staff during meetings to raise and develop awareness of these developing and what actions can be taken to mitigate against this.

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. The provider had identified a number of resources to support the service and upskill staff. Senior management had good oversight with frequent visits to engage with staff and oversee how the service was progressing in line with the provider’s values. Staff told us they had been enabled to develop their skills through further training and that management were approachable. One member of staff said, “We are always encouraged to progress with additional training like NVQ.” Another member of staff said, “The deputy manager has been mentoring me, and I feel quite confident in my role now. I have protected time to do the training I am on and feel this has made me more confident.”

The manager understood their responsibility under duty of candour and acted with honesty and integrity to report when things went wrong and investigated these. A relative told us they had made a complaint to the service about their loved one’s clothes, how they were not well fitting and creased. They went on to say they were happy with how the manager had dealt with this complaint.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt confident to speak up and raise any concerns. The provider had systems in place to support staff in speaking up. We had mixed feedback from relatives on communication with the service, some relatives told us they felt communication was good whilst others felt they did not always get prompt call backs from staff when they had raised queries.

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 we spoke with told us they felt they were treated fairly by the provider and had equal opportunities for development. The provider had systems to make reasonable workplace adjustments for staff with disabilities to support them in performing their roles.

Staff were provided with equality and diversity training to help them understand about protected characteristics, bullying and harassment. Staff we spoke with told us they had a good team and enjoyed working at the service with people.

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. The provider had good systems in place to give them oversight of the service and had provided additional resources and support to the service when issues had been identified. There was an active service improvement plan in place which the manager was working through with the provider to make improvements. This included addressing issues within the internal and external environment, staff training and the use of accurate up to date documentation at the service. Electronic systems for recording care and support needs had been implemented, and these were being adapted and reviewed to ensure all person-centred information was included in one place.

The manager had been well supported by the provider’s senior management team with frequent visits and input form the area manager, managing director, safeguarding lead and staff trainers.

Audits were completed and these were shared along with any incidents or accidents with the management team for discussion and action. The manager understood their responsibility to raise notifications to the appropriate authorities when required such as the CQC and local authority safeguarding team. The providers model of care met the CQC guidance for ‘Right Support, Right Care, Right Culture.’

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The manager worked with other healthcare professionals to ensure people’s healthcare needs were being met and reviewed. This included GPs, occupational therapist, physiotherapist, dentists and chiropody. Where people needed hospital reviews and specialist appointments, such as neurology, the manager actively pursued these services to provide follow up to people.

The provider and manager shared information and learning with partners internally and externally and collaborated for improvement. For example, the provider shared learning across their organisation from other services to mitigate risks and improve outcomes for people.

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 were encouraged to share their feedback during meetings and supervision to help with the development of the service. People’s care was reviewed with discussions with relatives and other healthcare professionals and their input and ideas sought for care delivery. The provider used tools and assessment frameworks such as the quality-of-life tool to measure outcomes for people and improve the quality of care and support they received.

The manager shared learning at the service from accident, incidents, complaints and safeguarding concerns to mitigate risks and improve outcomes for people. Staff had been encouraged to develop their skills with additional training to equip them with the skills they needed to support people as individuals, whilst taking a positive risk approach.