London Also known as Greenwich

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

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 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.

Relatives were happy with the care their family member received and felt the service was well run.

Staff reported that the registered manager was approachable and easy to talk with if they needed to raise any concerns.

Staff demonstrated a clear understanding of the ethos of the service and were confident in their responsibilities. They understood their roles and felt well supported by the management team. Comments from staff included, “Management are efficient and respond to my query or concern quickly”, and “I have big support from the management. They care about my wellbeing. They support me with trainings.”

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 time of our inspection, there was a registered manager in post. They were supported in the running of the services by a director, and care coordinator. The registered manager had the experience, capability and integrity to ensure the organisational vision could be delivered.

The registered manager had many years of experience working health and social care. They had the relevant qualifications, experience and knowledge to lead the organisation in the right direction.

The registered manager told us they had an open-door policy towards staff contacting them. Staff we spoke with were positive about the organisation and the support they received from the registered manager. Relative were happy with the leadership.

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

Relatives told us they felt they could raise issues with the provider, and they would be addressed. There were systems in place to support the practice of being able to speak up, including a complaints procedure and whistle blowing policy. The registered manager held regular discussions with staff and people and their relatives, giving them opportunities to speak up. The provider conducted surveys every six months which gave people and their relatives using the service the opportunity to provide feedback on the running of the service.

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 a policy in place on equality and diversity to guide practice in this area. Staff told us they were treated fairly by their employer. Staff recruitment was carried out in line with good practice. Staff confirmed with us the registered manager provided them with equal opportunities to trainings, and gaining further relevant qualifications.

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.

Systems were not always effective in assessing, identifying and managing risks to people. Risk assessments related to people’s chronic health conditions, potential environmental hazards risk assessments in people own home were not completed. Mental capacity assessments for people were not completed. However, during our inspection, the provider addressed these concerns.

Some policies were not reviewed and updated regularly.

The provider had various quality assurance and monitoring systems in place. These included six-monthly surveys of relatives, along with staff surveys. We saw the most recent surveys contained positive feedback about the service.

Unannounced spot checks and observations on staff were carried out by senior staff. Relatives and staff told us they felt the service was well-led.

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 worked effectively in partnership with external health and social care professionals to support coordinated and joined-up care. This included regular communication with relatives, GPs, local authorities and commissioners, and hospital teams. Care records showed that staff worked well with health and social care professionals when required to ensure people received appropriate care and treatment.

A regular survey was sent to people and their relatives to obtain their feedback about the service.

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 told us there were systems and processes in place to help ensure lessons were learnt when things go wrong. These included arranging specific training sessions for staff, team meetings and staff supervisions. This supported learning and helped drive service improvements.

There was a focus on continuous learning and improvement. For example, staff undertook regular trainings to help them develop in their role.

During our inspection, the registered manager was receptive and keen to learn and improve the service. The issues we identified during our inspection were addressed by the registered manager.