Mainwaring Terrace

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.

Staff and families described a positive, open culture at the service. Staff told us leaders were approachable and followed an open door approach, so they could raise concerns and ask for support. Families also said managers listened and acted when they raised issues. This helped create a culture where people’s needs and experiences mattered, and where the service responded to feedback.

The provider also had systems to support oversight and improvement. For example, records showed clear ownership and review dates for risks, which helped managers keep track of actions and follow them up. The provider had a development plan that set out planned improvements, including changes to the environment to better meet people’s needs. This showed the service had a clear direction for improvement and could describe what it was working towards.
 

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.

Leaders supported staff and families to raise issues and get a timely response. Staff described leaders as approachable and said they could ask for help or raise concerns. Families also said leaders listened and acted when concerns were shared, which helped build trust and confidence in how the service was run.

Leaders also provided oversight of safety and improvement. Staff gave examples of learning being shared across the organisation after investigations. The service had arrangements for routine safety oversight, including scheduled checks and regular reporting, which supported leaders to keep risks under review and act when needed. This helped leaders to make decisions based on information about quality and safety, and to support consistent practice.
 

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

Staff knew how to raise concerns and told us they felt safe to do so. The provider had clear routes to report concerns, including a named champion and an anonymous option through the Safe Call number. This made it easier for staff to raise issues in different ways and helped reduce the risk that concerns would go unreported.

Staff gave examples of speaking up in practice. One member of staff told us, “I'll call out when I see something that's not right. I can tell staff directly, and we have a good working relationship with each other.” This showed staff were confident to challenge poor practice and raise issues quickly. Families also said they could raise concerns with managers and saw action taken.
 

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 told us the provider supported fair and inclusive working arrangements. For example, staff described positive flexibility, including adjustments to support a return from maternity leave. This helped staff to feel supported and able to do their jobs well.

The provider also had arrangements to understand and improve workforce equality. Workforce diversity information and action plans were in place, and we did not identify concerns about equality or inclusion for staff at the service.
 

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.

Leaders had governance arrangements in place to monitor quality and safety. The service kept a risk register and an audit schedule. Staff described how they used these systems to share information and learning, so managers could identify issues, take action and keep risks under review. This supported a consistent approach to managing risk and improving care.

The provider was also strengthening governance through digital systems. They were implementing new care and incident management systems to support care records and workforce management. IT issues had delayed full adoption, but leaders continued to use alternative arrangements so monitoring and oversight could continue while systems were introduced. This helped maintain continuity while the provider improved how it recorded and accessed information. Families’ feedback supported our findings. They told us managers responded in a timely way to any concerns they raised.
 

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 service worked with external professionals to support people’s health and wellbeing. Staff described working with GPs, district nurses and therapists when people needed specialist input. This helped people to get the right support and helped staff to respond when needs changed.

The provider also supported people to take part in community life. Families described people having opportunities to go out and take part in activities, and records included community-related planning. This showed the service considered community access as part of support, which is important for people with a learning disability or autistic people to feel included and valued.
 

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.

Leaders supported improvement by sharing learning from incidents and using that learning to strengthen practice. Staff described how leaders shared lessons and helped teams to understand what needed to change. This supported a culture where staff could learn from what happened and improve the way care was delivered.

The provider was also introducing new digital systems to improve how the service worked. Staff told us training was ongoing as new systems were brought in for care planning and rota management. Leaders used these changes to strengthen record keeping and support more consistent ways of working. This helped the service to improve how it captured information and supported staff to access the guidance they needed.