Endorphins Group

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.

This is the first assessment for this newly registered service. This key question has been rated good.

This meant the provider 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. Staff understood the visions and values of the service.

The provider had a structured quality assurance cycle, with themed areas of focus throughout the year. This supported ongoing monitoring and improvement across key areas such as safeguarding and health and safety.

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.

Leaders demonstrated a strong understanding of service performance and risks. When concerns were identified, they took appropriate action to address them, including providing additional support to staff, escalating issues, and implementing action plans.

Relatives and staff consistently spoke positively about the leadership within the provider. They described leaders as approachable, responsive and supportive, and told us they felt comfortable raising concerns, sharing feedback and seeking advice. Feedback demonstrated that leaders maintained strong relationships with people, relatives and staff, creating an open and positive culture where individuals felt listened to and valued.

One relative said, “[The manager] is amazing. [They are] a good manager. [They] put us at ease, so we have nothing to worry about. [They] treat the staff well. We appreciate everything they are doing.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistleblowing policy in place, supporting staff to raise concerns appropriately. Managers promoted an open-door policy, and staff reported feeling comfortable and confident to raise concerns, contributing to an open and transparent culture.

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 promoted equality, diversity and inclusion within the workforce, creating an environment where staff felt respected, valued and able to be themselves. Policies and practices supported fairness, with staff encouraged to share their views and experiences, contributing to an inclusive culture which supported positive staff wellbeing and effective care delivery.

The provider used newsletters to share information and promote engagement across the provider. These included updates such as staff recognition through “shout outs,” introductions to new team members, upcoming events and a summary of activities from the previous month. Newsletters also highlighted national events, for example Mother’s Day, International Happiness Day and Mental Health Awareness, helping to promote awareness and inclusion.

The provider did not always have systems in place for good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There were inconsistencies with record keeping for compliments, complaints, supervision and team meeting records. The provider failed to maintain consistent and accurate governance records. Leaders responded positively to inspection feedback and promptly implemented actions to enhance governance, oversight and quality monitoring processes. The provider responded to our and implemented actions to improve monitoring of the provider.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners. The provider worked well with the local authority and local communities.

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 and effective practice. Leaders welcomed feedback throughout the assessment and demonstrated a proactive approach to continuous improvement and ongoing development.