Delight Support Services - Main Office

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 68 (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 registered manager demonstrated an understanding of their regulatory responsibilities and had identified priorities for the ongoing development and improvement of the service. Systems and processes were in place to support staff and contribute to a positive and inclusive culture. Staff understood their roles and responsibilities and described the management team as approachable and supportive. Staff feedback reflected a positive and open culture, with a shared commitment to delivering high-quality care and support. One staff member told us, “It [Delight Support Services] is a good place to work. Staff are kind and helpful and fully committed to doing their best for the people we support. Everyone works hard, and we all want to give the best care possible.”

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. A revised management structure had recently been implemented in response to the growth of the service and was in the process of becoming embedded. While arrangements had been introduced to strengthen oversight and accountability, further review may be required to ensure management capacity and support remain effective in meeting the needs of the service. Staff spoke positively about the support they received and described the management team as approachable and responsive. This was also reflected in feedback we received from people, families and partners. One partner told us, “[Name of Registered Manager] is highly regarded by colleagues and is an excellent ambassador for the organisation.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Systems were in place to enable people, relatives and staff to raise concerns and share their views. Clear complaints and whistleblowing procedures supported an open and transparent culture, helping to ensure concerns could be raised, listened to and acted upon appropriately. One staff member told us, “The manager and the care coordinators I have met are approachable and open to listening. I feel comfortable sharing any concerns or ideas.”

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 policies and procedures in place to promote equality, diversity, and inclusion, and staff had received appropriate training in these areas. Staff told us they felt valued, respected, and supported in their roles and the registered manager fostered a culture that was inclusive, fair, and respectful of individual differences.

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. Governance systems and oversight arrangements were in place; however, these were not always effective in identifying and addressing areas requiring improvement. For example, quality assurance processes had not identified shortfalls in recruitment checks, aspects of care recording, or some medicines management processes. Audits completed were not always sufficiently robust or comprehensive, and while lessons learned were identified, records did not consistently demonstrate how actions were monitored through to completion and embedded in practice. Although we found no evidence of harm to people as a result of these issues, governance systems required strengthening to provide effective oversight, identify areas for improvement and support continuous service development. The provider had recently revised the management structure in response to service growth; however, these arrangements were not yet fully embedded and would require ongoing review to ensure sufficient management capacity and robust oversight of the service. Where we highlighted areas for development during the inspection, the management team responded promptly, reviewing concerns and taking appropriate action to address them. The registered manager was aware of their responsibilities to notify partners. For example, notifications to CQC and safeguarding alerts were submitted when required. The provider had a business continuity plan which detailed how they would be prepared for emergencies.

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 demonstrated a strong commitment to the ongoing development and improvement of the service and was open and responsive to feedback. They recognised the importance of collaborative working and maintained positive relationships with a range of partner agencies and external professionals. Records evidenced effective partnership working, with appropriate advice sought and referrals made in a timely manner when required. This helped to ensure people received coordinated care and support and promoted positive outcomes. Feedback from partners was consistently positive. One partner told us, “They are a reliable service that usually goes above and beyond what most companies do.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. There were processes in place to promote organisational learning, and leaders described how learning from incidents, complaints and concerns was shared to improve practice. However, records did not consistently demonstrate how lessons learned were monitored or used to drive improvement and positive outcomes for people. Quality assurance audits were not always sufficiently detailed, limiting the provider’s ability to identify trends, monitor performance and evidence improvement over time. Following our feedback, the registered manager acted promptly to strengthen governance arrangements, auditing processes and oversight, demonstrating a commitment to ensuring governance systems were effective in driving continuous improvement in the future.