P & N Healthcare Services Ltd - Gloucester

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

The provider and registered manager had a clear vision for the service which was based on the provider’s values. The provider’s values were clearly displayed in the registered office and reminded staff to treat people respectfully, with compassion, and to promote their well-being and independence. The registered manager told us they aimed to provide person centred care and to support people to lead independent lives in their homes for as long as possible. The registered manager said, “We are client focused, led by the needs of the client. That is our purpose.” People using the service, their relatives and staff felt confident in the management and leadership of the service. Staff felt supported by the management team. We received comments from staff such as “Management is supportive. I think they do have the knowledge of the industry” and “It [the service] is quite good, I have no complaints, it is a good company.”

Feedback from people, their relatives and stakeholders were taken seriously and helped to influence the service and drive improvement.

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.

It was clear from our conversations with the registered manager and staff they were passionate about the service and had a clear understanding of their role and responsibilities.

The provider and registered manager used their own professional background to influence and shape the service. The registered manager had good oversight and used every opportunity to review the service and drive improvement. For example, we saw evidence of a compliments log which included considering whether positive feedback could lead to any further improvements in staff practices.

The provider shared their aim was to grow the service, however they wanted to ensure the quality of people’s care would be maintained and monitored by further developing their governance and monitoring systems if the service expands.

Regular staff meetings were held to provide staff with opportunities to discuss an incident, learning, training requirements, compliments and complaints. The outcome of audits and any action required to improve the service and practices were shared with staff.

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

There were systems in place to enable staff and others to speak up when they felt something was wrong. Staff explained they felt confident speaking up and had opportunities to express their views such as during supervision and staff meetings. One staff member said, “Yes, they [managers] are very good. They are very approachable and very nice.” The registered manager explained they always aimed to be honest and transparent when managing concerns or complaints and to take action to resolve any concerns raised by people, staff or stakeholders.

The provider had conducted a staff survey which received predominantly positive feedback.

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.

Staff raised no concerns about their employment. They told us their individual and diverse needs were respected. The provider had policies and procedures to support workforce equality, diversity and inclusion. The registered manager provided examples of how they supported staff and ensured their well-being.

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.

We saw evidence of an overarching quarterly audit which monitored aspects of the service and identified issues and trends as part of the provider’s quarterly management quality assurance processes. However, we found some of the audit findings were not always accurate or reported on some key aspects of the service such as staff punctuality, medicines changes and the monitoring of staff care delivery records. This was raised with the registered manager who agreed to evaluate their governance and auditing practice to monitor all aspects of the service.

The provider had not fully understood their statutory duty to provide learning disability and autism training to staff. However, the registered manager was responsive to our feedback and took immediate action to deliver appropriate training for the staff team following our assessment.

The registered manager was responsible for the day to day running of the service. The provider’s values promoted a culture of continuous improvement ‘by seeking feedback and striving for ongoing learning and further development in care practices.’

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.

The registered manager and staff understood their role and the importance of working in partnership, with people, their relatives and associated health care professionals. Staff worked with people’s relatives and health and social care professionals when they needed to coordinate and enhanced people’s care. Feedback from professionals and other monitoring authorities was taken seriously and acted on in a timely manner.

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.

The registered manager focused on continuous learning and developing the service. They said, “We want to learn and make improvements. We value any feedback both good or bad.” This included identifying areas for improvement through regular checks, audits, and reviews of care delivery. There was a culture of learning from incidents and feedback to drive improvement which was shared with staff.