YourLife (Shirley)

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• 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 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.

There were some shortfalls in the consistency of leadership and management during a period of transition. While staff and people understood the provider's values and objectives, the absence of a consistent management presence meant oversight and support were not always experienced consistently.

People and staff described the impact of not having a consistent management presence within the service. During the inspection, the registered manager remained responsible for the service but had been promoted and had already started a new role within the organisation. As a result, they were not always present at the service and support was being provided by managers from other locations while a new manager transitioned into the role. Staff told us this could affect consistency, with one staff member saying, “Support would be better if it was consistent.” People also commented on the impact of management changes. One person told us, “You can feel that there is not a consistent presence here at the moment.” Another person said that although support from other managers had been helpful, “different faces” meant information sometimes had to be repeated.

However, staff understood the provider's values and remained committed to supporting people to achieve their outcomes and receive care in the way they wanted.

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.

Staff spoke positively about leaders and described them as approachable and supportive. One staff member told us, “[the registered manager] was very welcoming when I started,” while another said, “It was nice to be able to speak with [the registered manager]. They are approachable and give us tips on how to improve.” Leaders were supported by a range of organisational teams including compliance, care coordination and care performance managers, which helped provide oversight and guidance. The registered manager described regular meetings, training opportunities and peer support networks that enabled the sharing of learning and good practice.

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

Staff had a range of opportunities to raise concerns and provide feedback, including regular team meetings, surveys and weekly service updates. Meeting records showed staff were encouraged to discuss any support they required, barriers to completing tasks and suggestions for service improvement. The provider also had a whistleblowing policy, including access to a confidential reporting service. Staff told us they felt able to raise concerns when needed, “The manager will always take time for us if we need to talk.”

However, staff told us that communication regarding rotas had not always been effective. One member of staff described occasions when they had been allocated shifts when they were not available, although they felt comfortable raising these concerns with managers.

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 completed equality and diversity training and had access to policies designed to promote fairness and inclusion. The registered manager described making reasonable adjustments where needed, including providing additional time and support for training and learning. Flexible working arrangements were also available for some staff, helping them balance their work responsibilities with other commitments.

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.

A programme of audits and oversight processes was used to identify issues and drive improvement, including checks of care records, staff files, daily records, medication management, training and the safety of the environment. Where issues were identified, action was taken to address them. For example, audits highlighted occasions where staff had not remained for the full allocated call time and this was followed up with staff. Business continuity plans and staff toolbox talks helped ensure staff were prepared to respond appropriately to a range of situations.

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 described working collaboratively with colleagues from other locations. The registered manager shared that they had buddied staff with another service already using the electronic system to support learning, transition and use. The service had also developed links with community organisations and support groups, including Age UK, carers' organisations and dementia cafés, which provided information and opportunities for people living at the service. The registered manager told us community engagement activities had reduced during a period of management transition; however, plans were in place for the incoming manager to strengthen these links and increase involvement with the local community.

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 worked with compliance and care performance teams to review performance, monitor risks and identify opportunities for improvement. Learning was shared through handovers, meetings and induction processes, helping to support staff development and consistency. Staff and managers described adapting support creatively to improve outcomes for people. For example, a gradual wellbeing approach was introduced to build trust with a person living with dementia, providing reassurance for both the person and their family member and leading to increased engagement with care. The service also encouraged people to participate in activities and community events, supporting their wellbeing and quality of life.