Emerald Agency

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 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 positive and person-centred culture, with a focus on supporting people to live independently and maintain control over their lives. Staff understood the values of the service and described a culture that promoted respect, choice and inclusion.

Staff spoke positively about the management team and told us they felt supported and able to raise concerns or share ideas. The registered manager was visible and approachable, and there was evidence of an open culture where staff felt comfortable discussing issues and learning from practice.

Observations showed that staff interactions with people reflected these values, with a strong emphasis on promoting independence, dignity and person-centred care.

The provider had leaders who were visible, supportive and demonstrated a compassionate approach to managing the service. The registered manager and deputy manager were actively involved in the day-to-day running of the service and worked alongside staff, including undertaking shifts and sleep-in duties, which supported continuity and accessibility for both staff and people.

Staff spoke positively about the management team and described them as approachable and responsive. They felt able to raise concerns, share ideas, and told us that managers were supportive and willing to listen.

There was a compassionate approach to leadership. For example, the registered manager provided additional flexibility to staff demonstrating consideration for staff wellbeing. People appeared comfortable and relaxed in the presence of both staff and managers, indicating positive and inclusive relationships.

Leaders demonstrated a good understanding of the people using the service and the needs of the staff team. This supported a culture where people and staff felt valued and included. The provider’s approach also reflected a commitment to supporting people’s human rights, with a focus on enabling people to live ordinary lives as part of their local community and maintain meaningful lifestyles.

The provider created an open culture where people and staff felt able to speak up and share concerns. Staff told us they felt comfortable raising issues with the management team and described managers as approachable and responsive.

There were a range of opportunities for staff to raise concerns, including day-to-day discussions, supervision and team meetings. Staff were confident that any issues raised would be listened to and addressed.

People also appeared comfortable expressing their views and approaching staff and managers when they needed support. This reflected a positive culture where individuals felt safe to communicate openly.

Leaders demonstrated a willingness to listen and respond to feedback. Actions taken during the assessment, including addressing gaps in staff competency checks, showed concerns were taken seriously and used to inform improvements.

The provider promoted an inclusive and respectful culture for staff. Staff described a positive and supportive working environment, and there was no evidence of discrimination. Interactions observed during the assessment reflected a culture of respect and inclusion.

Leaders demonstrated a flexible and supportive approach to staff, including making reasonable adjustments to support individual circumstances. Staff demonstrated an understanding of equality and diversity principles, and there was no evidence from people, relatives or staff to suggest discriminatory practice.

This supported an inclusive working environment where staff felt valued, able to raise concerns, and contribute to the care people received.

The provider’s governance and management systems were not always sufficiently robust and effective in identifying, assessing and mitigating risks to the quality and safety of the service. A range of audits and checks were in place, and the provider had identified key areas for monitoring.

However, policies and procedures were not always aligned with current legislation or best practice and did not consistently provide clear guidance for staff. This included areas such as safeguarding and governance processes, which reduced assurance that staff were fully supported to carry out their roles in line with regulatory expectations.

Systems to ensure staff were trained and competent were not consistently robust. While training records demonstrated completion, competency-based assessments, such as for medicines administration, had not been completed to ensure staff were able to carry out their roles safely and effectively. There was also limited evidence of how outcomes for people, such as those following health appointments, were systematically monitored to ensure any required actions were taken.

The registered manager responded to issues identified during the assessment and demonstrated a willingness to take action where concerns were highlighted.

Although people were receiving a flexible, person focussed service which met their individual needs the model of care was not always aligned with current best practice guidance. Agreements reviewed indicated that people were required to receive care from the provider as a condition of their tenancy, which may impact on choice and independence within a supported living model. This reduced assurance that the service consistently promoted the principles of ‘Right support, right care, right culture’, including enabling people to have full choice and control over their care and how their care was provided.

The provider worked in partnership with other services and actively supported people to be part of their local community.

Feedback from professionals was positive about the service, describing good communication and a collaborative approach to supporting people. The registered manager demonstrated a proactive approach to working with external partners, including following up referrals and coordinating care when needs changed.

People were supported to take part in community activities and maintain relationships that were important to them. This included accessing local facilities, attending social activities and engaging in meaningful routines, which supported their wellbeing and inclusion.

The provider also demonstrated a commitment to maintaining relationships during periods of change. For example, staff maintained regular contact with a person during a hospital admission, supporting continuity of relationships and emotional wellbeing.

The provider demonstrated a positive approach to learning and improving the service. Leaders and staff were open to feedback and showed a willingness to reflect on practice and make improvements where needed. The registered manager responded to issues identified during the inspection and took action to address areas of concern, including strengthening staff competency checks and reviewing supervision and communication processes. This demonstrated a commitment to improving the quality of the service.

There was evidence of a learning culture, with staff describing a no-blame approach and a focus on improving practice. Leaders and staff demonstrated an understanding of how to adapt support based on people’s changing needs. However, while improvements were made in response to issues identified, there was limited evidence to demonstrate how learning was consistently documented, shared or used to drive improvement across the service.