Pockets of Peace Care Ltd

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 75 (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. Leaders demonstrated a clear understanding of their regulatory responsibilities, as well as their priorities for developing the service. Staff were aware of their roles and responsibilities and felt involved in decisions about the service. They described management as approachable and said they felt confident raising concerns. Staff spoke positively about the service’s culture and overall morale. One staff member told us, “Staff morale appears to be positive with colleagues working well together and supporting each other. There is a collaborative team environment, and staff are generally approachable and willing to help. From my experience so far Pockets of Peace is a supportive workplace where staff are encouraged to communicate openly and work as a team to ensure good 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. There was a clear organisational structure in place, and staff understood their roles, responsibilities, and how they contributed to the service. The management team responded appropriately when issues arose and took action to drive improvements. Throughout the inspection, both management and staff demonstrated openness, integrity, and transparency. One staff member told us, “We are supported through supervision and debriefs after incidents. Pockets of Peace management listens to feedback and adjustments are made when concerns are raised.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Policies and procedures were in place to guide people and staff, including safeguarding and whistleblowing policies. We reviewed a range of records which showed that people’s views and experiences had been actively sought and valued. This included feedback gathered through surveys, as well as compliments and complaints. The provider demonstrated a commitment to listening to people, using their feedback to inform improvements and support the ongoing development of the service. Relatives told us they could raise concerns if they needed to and felt able to approach and speak with management and staff. One relative told us, “They are very approachable.”

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 recognised the importance of maintaining a fair and inclusive workplace. Staff received appropriate training and regular supervision. Feedback from staff confirmed that adjustments were made when needed to support their individual circumstances. The provider had clear policies and procedures in place relating to equality, diversity, and inclusion, and staff had completed relevant training in these areas. Staff told us they felt valued, respected, and supported, and that the registered manager promoted a culture that was both inclusive and equitable.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The provider had effective systems in place to monitor and continuously improve the quality of care delivered. Tools such as audits and quality checks were regularly used to assess the safety and effectiveness of the service, with actions taken to address any identified concerns. Where areas for improvement were identified, the management team responded promptly, reviewing and addressing the issues raised. The registered manager demonstrated an understanding of their regulatory responsibilities, including the duty to notify relevant partners although no safeguarding notifications had been required during the period reviewed. 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 management team demonstrated strong commitment to their vision for the service and were open to feedback, recognising the importance of working collaboratively with partner agencies. Records showed that positive and effective relationships had been established with external partners and professionals.

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. Systems were in place to learn from incidents and near misses, with records showing that lessons learned were identified, shared with staff, and used to reduce the risk of reoccurrence. The registered manager outlined clear plans for the ongoing development and improvement of the service, with a focus on enhancing outcomes for individuals. Policies and procedures were aligned with best practice and were readily accessible to all staff. Feedback was valued and used to improve the quality of care. One relative told us when asked if anything could be made better with the service, “No the service is very good. I can’t think of anything that could be better.”