Vesey Road

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.

This is the first assessment for this service. This key question has been rated good

This meant the service was consistently managed and well-led. Leaders and theculture they created promoted high-quality, person-centred care.

This service scored 64 (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 were confident to identify poor practice and told us concerns would be acted on by management. Relatives told us staff were kind and compassionate. Staff and management fed back passionately about the care being delivered to people and spoke fondly of the people they were supporting. The provider responded positively to the feedback we provided and demonstrated a willingness to make the improvements needed.

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. However, the registered manager did not always recognise issues prior to our visit and did not act to reduce risk where issues had been previously identified. Examples of these would be the unsanitary toilet brushes and the laundry room door lock.

Leaders were visible within the service and led by example to their staff team, demonstrating inclusive behaviours. There was a stable management and staff team. The registered manager was committed and understood their legal responsibilities. Where areas of concern were identified by us, managers were open, honest and committed to making the required improvements. Staff knew their roles, responsibilities and how to support each other. They told us they felt supported and valued by the management team. People and their relatives spoke highly of the staff and management team. They told us they knew who the management team were. A person told us, “The staff and managers are really good to me. Sometimes they have to say no when I want something, but they tell me why because it’s usually having too many sweets because it’s bad for me.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were provided with the relevant policies and procedures detailing what was expected of staff working for the service. Staff told us they felt able to raise any issues or concerns, including poor practice. Staff were confident senior staff would listen to them. They understood the whistleblowing policy with staff telling us how they feel empowered to report concerns by the registered manager.

Processes to seek the views of staff were well embedded; this included regular team meetings and individual staff supervisions. Where meetings were held, these were recorded, allowing staff who were unable to attend to review the content.

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.

There were processes for staff recruitment and induction. Staff received training relevant to their roles. Staff felt respected and able to work in an environment that was supportive and free from discrimination. Support and reasonable adjustments were in place for staff when needed.

The provider’s governance systems were not always effective. These systems had not enabled them to address the shortfalls in risks we identified during our inspection. The provider’s own audits had identified safety shortfalls with Infection control regarding toilet brushes, but these had not been addressed in a timely manner and this put people at risk of harm. We found peoples files had been stored in an external building which was unlocked. The registered manager had not identified the risk of a breach regarding people’s personal data. However, the registered manager immediately had the files relocated to a secure environment when this was brought to their attention. The registered manager had previously discussed toilet brushes in a team meeting and how they may impact hygiene standards in a team meeting, however, this did not translate into firm action.

There was a programme of internal and external audits and checks to monitor the quality of the care provided. These were not analysed for trends; however, the registered manager and provider recognised that trend analysis is important in risk mitigation. They told us that they would start a programme of analysis.

The registered manager understood their responsibility to provide honest information, and to apply the duty of candour where appropriate. People and relatives spoke highly of the staff and management team. The provider responded promptly to our inspection and took some immediate actions during and following our site visit to ensure the safety and wellbeing of people. This included reviewing their own systems and processes in place.

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.

Partners had positive experiences of working with the provider to collaborate on the delivery of safe, high-quality care to people. A health and social care professional told us, “It is clear that the manager and staff at Vesey Road really love their patients [sic]. They make sure they always ask for appointments and advice when they need it and follow healthcare instructions well.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The lack of analysing trends in incidents and accidents risked that opportunities could be missed to reduce the likelihood of these events happening again. However, the registered manager demonstrated they wanted to drive the improvements in people’s care and told us they were committed to doing this.

The service supported people with a learning disability and autism and was aware of current best practice guidance including right support, right care, right culture. We saw and records confirmed people’s independence was promoted, and people were supported to have goals and enjoy a full life. For example, people were supported to enjoy a range of leisure activities, days out and holidays. People were supported to do everyday tasks and their independence promoted.