Elliot Avenue

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 requires improvement. At this assessment the rating has changed to 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 71 (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 culture at the service was positive and the management team understood the importance of aligning the care services values with the Care Quality Commission (CQC) ’Right support, right care, right culture’ guidance. The management team had a clear vision for the service, and this was shared with the staff team.

Observations showed that staff respected the service as people’s home and people chose how they wanted to spend their time. Staff told us they felt supported and listened to by the management team. They understood the values of the service and told us they worked well as a team. A staff member told us, “I have been here a long time, I know people well. People can come to me, and I will share my knowledge and experience.”

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. However, this provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our assessment there was no registered manager in post.

Staff had a clear understanding of their role and responsibilities and told us there was a positive culture at the service. The managers and staff knew people they supported well and were clear on their role and responsibilities and the systems and processes in place. People interacted positively with the managers and found them approachable. Staff and relatives gave us positive feedback regarding the management team at the service. One staff member told us, “I feel valued by the management team.” Another told us, “My immediate line management always supports my wellbeing…They have helped me so much and fully supported me.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The manager told us about the provider forum and workshops that encouraged staff to get together to discuss initiatives. Staff could also meet with the provider’s chief executive team should they choose to do so.

Staff told us they felt supported by the manager and could raise suggestions or concerns. Staff understood the values of the service, and that their role was to also make the people who used the service feel cared for, respected and valued. They understood the term "freedom to speak up" and were confident if they had any concerns they would be listened to.

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 was a diverse workforce at the service. We saw staff were included in discussions surrounding the support provided at the service. A staff member told us, “I feel supported by my manager, and I feel listened to.” The provider supported staff equality and staff told us they were encouraged to be involved in the service and discussions, such as updating people’s care records. The provider’s recruitment was equitable and fair.

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 management team had a good oversight of the service and risk, including the quality of people’s care and support. They completed daily, weekly and monthly quality and compliance checks. This included the auditing of safe medicines management, and safety checks including fire safety and equipment checks. Actions were taken when improvements were required.

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. Managers had good working relationships with partners including community health and social care professionals. We saw evidence of effective partnership working, information sharing and collaboration to ensure people had a good quality of life.

The provider focused on continuous learning, innovation and improvement. The management team had a service improvement plan in place based on the findings from internal and external audits and monitoring of the service. Actions were recorded where required and monitored to help ensure that areas of improvement required were implemented to enhance the quality of the service provided to people. Staff told us they were encouraged to be involved in discussions on how to improve the service for people.A staff member told us, “I do feel comfortable raising suggestions.”