National Star College - Ullenwood

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• 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 outstanding. 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 82 (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.

Leaders promoted a positive and person-centred culture where people were at the heart of decision-making. Staff consistently understood the provider's values and described working towards shared goals. Leaders engaged with people, relatives and staff to understand their experiences and used feedback to shape service development. The culture promoted openness, collaboration and continuous improvement, helping to achieve positive outcomes for people. A relative told us, “We are very happy and feel very blessed because we’ve got the chance to be there.”

Staff shared a strong understanding of the service’s values and worked collaboratively to achieve outstanding outcomes for the people they supported. The provider valued their leadership team and invested in management training skills to equip leaders with essential management skills. They also identified future leaders and invested time and training to support staff to reach their potential. All staff were included and encouraged to progress with formal health and social care qualifications. One staff member told us, “I have been given so many opportunities at National Star. I did A level English here, level 2 maths here and then came into residential. We have a good reputation for building up staff to go through promotions.”

The provider had exceptionally 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 always did so with integrity, openness and honesty.

Leaders were visible, approachable and acted with integrity, openness and honesty. Staff spoke positively about leadership and described feeling supported in their roles. Leaders promoted an inclusive culture where people and staff were treated with dignity and respect. There was evidence that leaders understood the challenges facing the service and responded proactively to support high-quality care and positive workforce wellbeing. A staff member told us, “The whole leadership team here has really driven change. We need the pioneering work as our student cohort is forever changing.”

Managers championed equality, diversity and inclusion across the service, ensuring people’s rights were upheld and all staff were treated fairly. Staff told us managers had made amendments to training specifically to support their learning needs, and they listened and understood when they experienced health issues.

The compassionate, values driven leaders helped create a highly stable, motivated, and confident workforce. A residential manager told us, “As an organisation we have changed beyond recognition. We need constant change management and the best equipment, professionalism, and right people in the right roles, which makes me feel very safe. We have working parties where we all get together to troubleshoot and sense check each other. We have different eyes and so managers go into different units to do audits etc. Managers always share good practice. We all want to be better and do better every day.”

Without exception, people spoke positively about the registered manager and their exceptional commitment to the service. A residential manager said, “The registered manager is really responsive. [They are] always asking for feedback. [They do] a lot to make sure they are approachable.” Another residential manager said, “As a manager I always want to grow and learn. [The registered manager] is incredible. I didn't know people like [the registered manager] existed until I worked here. [They are] phenomenal. [The registered manager] will not stop until we have everything we need. We are looking at a system that needs improvement and [the registered manager] is going [to the Netherlands] to look at systems they have there.”

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

Staff told us they felt comfortable raising concerns and were confident these would be listened to and acted upon. Systems such as team meetings, supervision and feedback mechanisms supported open communication. The provider promoted openness and transparency across the service, and we heard that leaders were responsive to concerns and learning was shared where appropriate. A staff member told us, “My managers really listen to me and I have always felt that I could say what I feel. I have had great managers and continue to have great managers in all the years I have worked at the National Star College.”

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.

The provider valued diversity and promoted an inclusive working environment. Staff told us they were treated fairly and with respect, regardless of their background or personal characteristics.

Equality, diversity and inclusion were reflected in policies, training and recruitment practices. Staff had access to support and reasonable adjustments where required. Leaders monitored equality issues and took steps to strengthen inclusivity and belonging across the workforce. In the most recent provider information return (PIR), the provider spoke about disability inclusion, “We are implementing a new process for accessing reasonable adjustments—including assistive technologies. This aims not only to support employees in achieving their best from the outset but also to ensure ongoing review of the effectiveness of those adjustments and the exploration of new support mechanisms as they become available.”

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 provider had governance systems and processes that supported the delivery of good quality care. Audits, monitoring activities and oversight arrangements were used to identify risks and drive improvements. Leaders reviewed performance information and acted when issues were identified. Systems enabled the provider to assess the quality and sustainability of the service, although the provider recognised the importance of continuous development and continued to strengthen oversight and systems on an ongoing basis. For example, they had completed a lessons learned exercise in response to a safeguarding incident and identified key learning, implementing improvements, including a policy review, to mitigate the risk of a similar occurrence. This showed the provider used information effectively to support decision-making and improvement.

There was a board of governors who brought a range of skills and expertise and oversaw the running of the college. We reviewed the governor activity and saw they were actively involved in supporting systems of accountability and good governance. The chief executive told us, “Over last 2 terms we have had governors come in and do shadowing, it has given governors the opportunity to learn more about what we are doing here and have much more insight. People see the presence of the governors as a good thing.”

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.

Staff collaborated well with health and social care professionals and maintained positive working relationships with external agencies. Information was shared appropriately to support joined-up care and ensure people's needs were met. The provider actively sought opportunities to strengthen community connections and promote inclusion, helping people access services and activities that mattered to them. One healthcare professional told us, “I feel the college give an excellent service, they are proactive about medical care…and ensure that [people’s] safety is at the top of their agenda. I have regular communication with [staff at the college]. I have recently done a training session for nursing staff at the college [to continually upskill and support them in a specific area].”

There was a clear commitment to strong partnership working, with positive relationships established with external professionals. For example, we saw how staff had supported change when working with secondary care colleagues to develop and improve the pathway for people accessing hospital. A residential manager said, “We have improved a lot over the years. [We always have] new ideas and communicate well. We work well with other organisations. We are not a closed community and we are open to new ideas.”

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.

The provider demonstrated a strong commitment to learning, improvement and innovation. Leaders actively sought feedback, reviewed incidents and shared learning to improve outcomes for people. Staff were encouraged to reflect on practice and contribute ideas for service development.

Quality assurance systems were evident, including regular audits, reviews, and checks that supported the identification of areas where improvements were needed.

Policies and procedures had been reviewed and strengthened in response to learning from incidents, as well as feedback from families and staff.

The management team were open to the feedback we gave throughout the assessment and showed a willingness to continually improve the service and achieve exceptional outcomes for people.