UBU - Harrogate

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 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, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The organisation’s values and expectations were emphasised to staff in conferences, training and team meetings. Most staff told us there was good teamwork and a positive, person-centred culture. One described the culture as being “'Friendly and welcoming. The values are about being open, honest and respectful. We accept people for who they are.” Staff feedback and our observations showed staff were focussed on ensuring people had a good quality of life. A relative told us they were, “Very happy. It’s very caring, one big family.” One person told us, “I like living here. I am happy.”

Where any concerns had been raised about culture and practice in individual support locations, action was being taken to address this. The senior management team’s open approach helped foster a positive culture.

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.

There was a strong management structure in place. There were two registered managers, with overall responsibility for the service, and they worked alongside a senior management team. They visited individual support locations regularly. There was also a structure of local team leaders for individual support locations. One told us, “Every month we have a manager’s meeting. This is to support each other with any problems. We can discuss and share knowledge.” The provider encouraged staff development and the opportunity for promotion within the company.

People knew who the managers were and could talk to them about any concerns. Most relatives felt the service was well-led and told us managers were approachable and responsive. Their comments included, “We feel confident that we can approach management and senior management if any issues were to arise.”

Staff felt supported and many described their managers as “approachable”. One told us, “[Registered manager] does my supervision and it is open and honest 2-way. I feel listened to, especially around training.”

The registered managers were aware of regulatory requirements and kept up to date with best practice via regulatory and local authority updates, provider forums, and bulletins from organisations such as Skills for Care. This helped ensure the leadership team had appropriate skills and knowledge.

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

People and staff were encouraged to share any issues or concerns. The provider had a whistleblowing policy and staff were aware how to report any concerns to their manager or via email to the provider’s ‘speak up’ lead. Staff confirmed they would feel comfortable raising anything and most said they were confident any issues they raised would be quickly acted on.

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 had relevant recruitment and equality and diversity policies to promote an inclusive workforce. Managers worked to ensure there was equity of opportunity and experience for staff.

Staff spoke positively about the diversity within their teams, including the opportunity to share experiences of different backgrounds, cultures and food for instance. One told us, “Everyone is respectful of other religions and faiths.” Some staff also spoke of the positive impact there had been to the consistency of the workforce since the provider had recruited some additional staff via their international sponsorship license.

The provider had clear responsibilities, systems of accountability and governance. They acted on information about risk, performance and outcomes, but some improvement was required to ensure fully effective governance.

The provider completed regular audits and checks to monitor the quality of care delivered. This included audits conducted by local team leaders and a quarterly ‘continuous improvement audit’ for each support location conducted by senior management. These had been used to effectively identify and address some issues, and to promote good quality care to people. However, some of the issues we identified during our assessment, such as those relating to medicines records and other aspects of record keeping, including the Court of Protection register, inconsistency of post incident records and debriefs, and minor anomalies in support plans, had not all been identified or effectively addressed by the governance systems in place.

The provider usually submitted required information to CQC in a timely way, about relevant incidents at the services. However, one notification was sent retrospectively. This meant there was a small delay in CQC being able to review the information to ensure the matter had been dealt with appropriately.

This all showed some improvement was needed to ensure systems operated fully effectively. The provider was in the process of implementing a new electronic support planning system and they explained how they anticipated their new system would help them enhance their governance and oversight moving forwards.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and collaborated for improvement.

The provider worked with a range of health and social care professionals to ensure people’s health and wellbeing needs were met. This included working in partnership with GPs and health specialists.

The provider had a strong focus on ensuring people were active members of their local community. They worked with other organisations to support people explore volunteering and educational opportunities. People also engaged in a wide range of social and cultural activities, including meals out, church attendance, and use of sports and leisure facilities. One person had recently completed a podcast and was proud of their involvement and the opportunity to contribute to the project. This all helped promote people’s social connections and community engagement.

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.

Since our last assessment the provider had developed their systems and increased their use of technology. They were also in the process of continuing to develop this further, by changing their electronic care planning system. The provider held regular staff conferences and a range of management meetings focused on specific areas of practice. These were used to review performance, share learning, and identify opportunities for continuous improvement. Managers also actively encouraged staff to contribute ideas and suggestions through team meetings. The provider had membership of relevant organisations, such as the British Institute for Learning Disabilities and the Restraint Reduction Network, to keep up to date with best practice and new innovations.

Incident reports and audits were used to identify any learning opportunities. Whilst audits had not always been fully effective in addressing all issues we found during the assessment, overall there was evidence of a commitment to continual improvement. The management team were very responsive to feedback throughout the assessment process.