The Care Advantage

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 newly registered service. This key question has been rated 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.

Family members shared that staff were aware of their own boundaries and provided care and assistance in the manner most suited to people’s preferences. One relative said, “The staff are professional and to [people’s] needs on a personal level.”

The provider established a clear vision and set of values, ensuring these were regularly shared with all members of staff. This transparent approach helped everyone understand the overall goals and principles for the service.

The service had policies and procedures to help facilitate clear communication across the staff team. This gave guidance to staff to help ensure that all were informed of important updates which were easily accessible to everyone who worked at the service. Regular team meetings and written protocols further supported the sharing of key messages and expectations.

Staff felt supported by the registered manager, who operated an open-door policy, making themselves readily accessible to people, their families, and staff at any time.

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.

The service was overseen by both a registered manager and an assistant manager, who each brought extensive experience and a strong understanding of people's assessed needs. An on-call system operated during weekends and overnight, allowing staff to contact management for support whenever necessary. Staff and relatives confirmed that they knew how to contact the management team.

Staff were consistently positive regarding the support offered by the management team. They said that the service had an open-door policy, which encouraged a welcoming and approachable atmosphere within the workplace. One staff said, I receive updates through communication with management. I feel well supported and given opportunities to develop my skills.”

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

Relatives reported that they were offered different methods to share their feedback regarding the service. For instance, one relative stated, “I know who the points of contact for are. When I contact the [management team] they are always on hand to help and do everything they can to arrange last minute extra bookings, thank you [we hugely appreciate the support we receive]

Staff reported regular team meetings for sharing concerns and suggestions to improve the service. They also noted that senior staff were approachable and open to discussions at any time. One staff told us, “I share information in staff meeting, also the origination has other ways we can speak up for an example I could use the Whistleblowing policy and report concerns about unsafe or poor practice. I can also contact external bodies like CQC if needed."

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 shared that they had the option to work flexibly, choosing shifts that suited their needs, such as weekends or evenings. This approach contributed to a better work-life balance across the team.

Staff completed training sessions designed to enhance their understanding of equality matters and to ensure everyone was fully aware of their entitlements and obligations.

It was observed during the assessment that new employees undertook an induction process specifically designed for the service, which supported a smooth transition and enabled them to integrate effectively with the team.

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.

The organisation had systems to oversee operations, manage risks and assure quality, enabling leaders to deliver care that was both safe and consistently reliable. For example, the service had scheduled audits in place to review care plans, ensuring that they remained up to date and accurately reflected each person’s support needs and preferences.

The organisation had effective systems in place to monitor its operations, address risks, and uphold high standards of quality. These measures supported the leadership in providing care that was not only safe but also consistently dependable. For instance, the service conducted regular audits of care plans, helping to ensure they were always current and accurately matched to each individual's needs and preferences.

Leaders understood regulatory responsibilities and the need to maintain accurate records and notifications. Staff said they received clear guidance when needed. This showed governance processes supported ongoing improvement and safe care delivery.

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 provider worked with external partners to ensure people received coordinated support and remained connected with the right agencies.

The provider work in partnership with external organisations to help people receive support and remained connected with the right agencies. The assistant manager said, we would give advice and signpost people or their relatives to the relevant agencies if required.”

The review process actively included people and their families, with information and updates being communicated in a straightforward manner. This demonstrated that the service worked well in partnership with others to achieve better outcomes and provide support for people within the community.

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 service focused on continuous improvement by reviewing all events and addressing issues for meaningful change. This approach helped identify causes, spot trends, and turn incidents into learning opportunities for the organisation.

Staff reported that they were provided with opportunities to contribute to the development and enhancement of service feedback. One staff told us, “The manager always involves us with developing the service this can be in staff meetings or in supervisions. We are also asked to give feedback on what we learnt from training.”