Archived: Mellieha

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 service 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. People were at the centre of their support when decisions about their lives were being made, and professionals, advocates and relatives when appropriate were involved. The service had processes in place to identify any early signs of a closed culture so appropriate action could be taken.

The service 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. People’s human rights were embraced and the service focused on care plans and person centred approaches ensuring people could live good, meaningful lives and access and be part of their local community.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had regular engagement with people and allowed them to engage as they felt comfortable. One person told us they chose to write letters to management which we observed. People told us management were available and spent time talking to people. The management also engaged with other professionals, advocates and relatives and encouraged a strong focus on people living the life they choose.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Generally, all the feedback we received from staff was positive and although some staff felt they sometimes might not see managers regularly out of office hours, evenings or weekends and that seniors held a lot of responsibility at this time. All staff told us they felt listened to and supported by the managers and the service.

On a previous inspection breaches were found in relation to good governance. We found the service had made improvements and was no longer in breach of regulations. The service 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 service had good governance arrangements and now had 3 managers at the service, 1 who was registered with CQC, and the other 2 in the process of registering. Support plans and risk assessments relating to people were completed and person-centred and contained a good level of detail. We found the provider to be responsive, open and transparent during the assessment. The service was introducing electronic care records and recording and although this process was ongoing, they were able to provide the information required. The managers completed regular audits and had good oversight of the service, and this was evident during the inspection.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement. We saw regular engagement with partners and the service was completing prompt referrals to partner agencies when necessary. We saw evidence of meetings with agencies and involvement of advocates to ensure focus on enabling people to thrive, develop skills and have new experiences.

The service did not always focus on continuous learning, innovation and improvement across the organisation. We received feedback from people and relatives they could not use the phone line at the service and had to contact staff on personal mobile numbers for updates on loved ones. We discussed this and handed over the information to managers very early in the assessment. However, we found this still to be an issue during our assessment and provided this feedback again to managers. The service did actively contribute to safe, effective practice and research. The service was working with people, their representations and staff to build a culture that focused on enabling people to enjoy a full life.