Aspire Hub 1

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 changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 61 (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 felt valued and people felt included. Comments included, “Things have come up and they’ve listened to families. They manage customer well, have meetings and put things in place for customer for the benefit of the customer” and “I feel able to raise concerns with the manager. I do feel supported in my role. The manager is approachable.”

Not all leaders understood the context in which the provider delivered care, treatment and support. Due to concerns found during our inspection, we could not be assured the leadership and governance of the service was good.

The management team were inclusive and compassionate about the people they supported and staff. Staff told us the management team were open and honest. Staff told us, “The management team have the appropriate skills, knowledge and experience” and “When on shift and if something comes up, when I speak with the manager, they will support you. Anything about the customer is their priority, they understand every perspective of human life. They provide a person centred service, they care for the staff as well as the customer.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There were clear whistle-blowing procedures in place and staff told us they felt comfortable to raise any concerns. Comments included, “I feel able to raise any concerns with the manager. I am very well supported in my role” and “Managers are very approachable, possibly the best management team I have worked with, approachable and friendly.”

The provider told us they valued diversity in their workforce. They told us they worked towards an inclusive and fair culture by improving equality and equity for people who worked for them and adjustments made where possible to support staff with their personal circumstances. The provider had policies and procedures that protected staff’s human rights and working conditions. Staff consistently told us they were treated equally and raised no concerns about discrimination.

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. The provider had a governance system which included a series of quality audits. These included audits for medicine management and care planning. However, the systems had not always identified issues we raised during the assessment. The lack of effective monitoring systems meant issues may not be identified and lessons may not be learnt when things went wrong. This evidenced systems and processes of governance were not robust or effective to ensure concerns were identified and actioned in a timely way.

However, the registered manager did understand their responsibilities in relation to their regulatory requirements around notifiable incidents. Our records indicated they notified the CQC in a timely manner about any incidents and events they were legally required to.

The service 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 management had developed good links and worked closely with health professionals.One relative said, “First sign of anything they contact the doctor or whoever needed.” We saw evidence of referrals to appropriate health professionals when needed some including the speech and language therapy team, general practitioners and social workers.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Systems in place at the time of assessment did not provide sufficient or consistent oversight of the service. This reduced the ability of the provider to review information and complete lessons learned, presenting a potential risk to people.