21 Hartsworth Close

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 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.

Staff told us the expectations of their roles were clear, and the organisations values and objectives were regularly reinforced through team meetings, supervision and training. Staff demonstrated and understanding of the provider’s vision and how this translated into the delivery of person-centred care.

The registered manager described how the provider’s culture was centred on achieving positive outcomes for people. They explained that staff, managers and senior leaders worked collaboratively to ensure people received high-quality, person-centred care and support. This shared commitment was reflected in the consistent approach taken by staff and the positive experiences reported by people, their relatives and professionals.

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 we spoke with told us the management, including senior managers were empathetic and supportive towards them. Staff told us they knew all levels of management and engaged with them regularly and had the confidence to talk about anything which concerned them.

A professional told us, “The manager leads by example with a calm, compassionate and professional manner, they go above and beyond their duties.”

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

The provider had systems in place for people, their families and visitors to offer feedback with a ‘comments box’ by the front entrance which people could use anonymously. Staff told us the management, including senior management were always present within the service or could be contacted at any time if there were any concerns.

The provider had policies in place such as a complaints policy which was also in pictorial form and a whistleblowing policy for staff to follow to share concerns.

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 registered manager ensured staff had access to training to be able to do their jobs and further their employment opportunities.

The provider had policies and procedures in place which meant staff were recruited fairly, seeking a mix of backgrounds and skills that would meet the needs and enhance the life of the people they supported.

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 and shared this with professionals, using the information to improve their service.

There were robust quality assurance and auditing systems in place. Audits identified clear actions and were regularly reviewed to monitor progress, evaluate the effectiveness of the improvements and identify further action required. Audits were completed across a range of areas, including the environment, operational systems and feedback received from people living at the service and their families. Findings and actions arising from these audits were incorporated into the service’s annual improvement plan.

Records demonstrated regular meetings involving managers at different levels of the organisation to review findings, monitor progress against actions and maintain oversight of the quality and safety of the service.

The service was led by a competent and experienced management team who worked collaboratively to provide high quality care and support. Staff, people using the service, their families and professionals were consistently positive about the leadership of the service and the support provided by the management team.

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 provider proactively worked with other agencies and sought to learn as much as possible to improve their service. They told us how they had engaged with the local authority’s quality team to gain professional feedback about the quality of service they were offering.

A professional we spoke with told us, “The manager and staff have maintained a high standard of care in the years I have known them. I am genuinely very impressed with their support and am happy to recommend them to anyone needing this type of support.”

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 provider showed a willingness to embrace systems and technologies that would enhance the quality of care they delivered. They told us about a number of electronic care planning and human resources systems they had implemented over a period of time and told us how this was helping them to be more organised.

The provider told us about improvements they had made within the service and about the future plans for their expansive garden with a view of making it a more accessible, user-friendly space in the future.