Three Roses

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.

The provider was previously in breach of legal regulation in relation to governance. Improvements were found at this assessment, and the provider was no longer in breach of regulations.

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.

The provider's aims, values and expectations were shared with staff and were also made available to people and their relatives when support commenced. People and their relatives spoke positively about the culture of the service and told us the management team promoted a supportive environment.

The registered manager described the culture of the service as, “Providing care in a person-centred care, making sure people are cared for and not exposed to harm at all. Also making sure our service has integrity, openness and accountability, and selflessness.”

Staff spoke positively about working for the service and described it as a good organisation to work for. They told us leaders were approachable and supportive, and that there was a shared commitment to providing high-quality care.

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.

At the previous assessment, concerns were identified regarding leadership oversight and regulatory knowledge. At this assessment, we found improvements had been made. The registered manager demonstrated an understanding of their regulatory responsibilities and had taken appropriate steps to strengthen governance and oversight within the service. They had also reduced their involvement in providing direct personal care to focus on managing and monitoring the service, to ensure they had sufficient oversight of quality and safety.

The provider had strengthened operational arrangements by employing care coordinators who were available to support care delivery and respond to emergencies when required. This enabled the registered manager to maintain effective leadership of the service.

Staff spoke positively about the registered manager. Comments included, “The manager is nice, if you have any concerns, they will fix, they are quite efficient, we can rely on them.”

The registered manager had also sought additional support from an external quality organisation and told us they valued the guidance available from local authority teams.

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

Staff told us they could speak to leaders about any concerns they had. They said they had access to regular team meetings and supervisions which enabled them to have their voice heard. One comment included, “I feel able to speak up. The main issue is the rota which has been talked about. The manager is lovey person, listens, acts, will meet us halfway. They encourage us to say any concerns and want us to work together, they listen.”

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 registered manager demonstrated an understanding of their responsibilities in relation to equality, diversity and human rights and was aware of the importance of ensuring fair and equitable practices across the service.

Staff provided positive comments of working with the provider. Comments included, “There is equal opportunities for everyone,” and “I’ve never experienced discrimination.”

Policies and procedures were in place to support equality, diversity and inclusion, and staff had completed training in equality, diversity and Human Rights. Through discussions with staff, they demonstrated an understanding of respecting people's differences and promoting inclusive practice.

The provider also sought regular feedback from staff to understand their experiences and identify opportunities for improvement. However, feedback surveys were not always anonymised. The provider recognised this and told us they would introduce anonymous feedback in the future to further encourage staff engagement.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

At the previous assessment, we identified shortfalls in governance arrangements. While improvements had been made, further work was needed to ensure governance systems were consistently effective in identifying, monitoring and addressing risks across the service.

During this assessment, we found some ongoing areas for improvement relating to medicines management, staff recruitment and the monitoring of staff visit times. We also found recruitment records were held across multiple systems, making oversight and the retrieval of information less effective. The use of multiple systems for managing records had also been identified at the previous assessment, and work was still ongoing to consolidate information for accessibility.

We identified some inconsistencies within policies and procedures that required updating to ensure they accurately reflected current practice and guidance. The provider responded promptly to our feedback in this area, making the necessary amendments and providing evidence that these changes had been completed.

However, despite these concerns, governance arrangements had improved since the last assessment. Care plans and risk assessments were more detailed and provided clearer guidance for staff. The provider had engaged an independent quality assurance professional who completed regular reviews of the service and provided additional oversight. In addition, a programme of audits was in place, helping leaders to identify areas requiring improvement and monitor progress against action plans.

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.

People told us the provider worked effectively with other professionals on their behalf and supported them to access the services they needed. Feedback from professionals was positive, with partners describing the provider as responsive, open and transparent in their communication. They said communication was timely and effective, helping to ensure any concerns or changes in people's needs were addressed promptly.

Leaders described how they regularly attended meetings with external organisations and stakeholders to share knowledge, learn from best practice and keep informed about developments within the health and social care sector.

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 and research.

Leaders spoke positively about their future plans and their ambition to expand and develop services within the local community. This included plans to purchase a property to provide supported living accommodation, helping to increase opportunities for people to live as independently as possible.

The provider had responded to the findings of the previous assessment and had implemented several improvements. Governance processes had been strengthened, care planning documentation had improved, and additional oversight arrangements had been introduced to support the safe and effective running of the service.

Leaders demonstrated a willingness to learn, seek external support and act on identified areas for improvement. They remained focused on embedding changes and ensuring effective oversight was maintained to support the continued delivery of the service.