49 Bath Road

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 79 (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 created a culture focused on enabling people to live meaningful and fulfilling lives. Observations and staff feedback showed a compassionate and inclusive environment where trust, learning and person‑centred support were prioritised. Staff said they felt listened to and valued. One staff member said, “Managers really care about our wellbeing so we can provide the best support to people,” and another said, “All of our opinions are welcomed, we are a team.”

Leadership was visible and actively involved in day‑to‑day practice. Managers and team leaders worked alongside staff, modelling expected behaviours and maintaining high standards. A team leader said, “Most important is that I am a good role model for my team,” which reflected a culture of accountability and support.

External professionals consistently described leadership as open, proactive and improvement‑focused. One professional said the service was “collaborative and pro‑active in nature” and that leaders showed a willingness to “seek out support” and act on advice promptly. Leadership was also described as providing a “stable and structured framework” supported by effective senior staff oversight.

Staff and professionals said the culture supported reflection and development. A behavioural specialist noted leadership was “open to feedback and motivated towards ongoing improvement,” and staff were willing to engage in reflective discussions about practice.

The culture promoted positive outcomes for people. Professionals highlighted that coordinated, values‑driven working had contributed to individuals “thriving” following complex transitions and reduced behaviours of concern.

A positive and inclusive culture supported continuous improvement and good outcomes for people.

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.

Leaders were actively involved in the day‑to‑day running of the service and worked alongside staff to maintain standards and provide direct support when needed. Governance arrangements were clear, with defined roles across the leadership team and effective oversight through senior staff, which supported consistency and accountability in practice.

External partners described leadership as proactive, well‑structured and responsive. The service was reported to work in a “collaborative and proactive” way, seeking external advice when required and implementing recommendations appropriately. This supported safe, coordinated care and continuous improvement.

Leaders set clear expectations for staff practice and promoted high standards. Staff were supported through supervision, training and career development opportunities, which contributed to confidence, competence and a stable workforce. Staff described a supportive environment where managers were approachable and responsive to wellbeing needs.

Staff spoke positively about leadership and support. One staff member said, “Managers really care about our well‑being so we can provide the best support to people.” Another said, “It is really fantastic to work here… the learning never ends.”

Staff also had access to an independent, confidential speak‑up and wellbeing service, available at all times, which supported staff to raise concerns or seek advice outside the organisation. This showed leaders created a supportive environment where staff felt valued and able to develop in their roles.

Leaders focused on improving outcomes for people, including those with complex needs. External professionals expressed confidence in the service’s ability to manage complexity and deliver positive outcomes through coordinated, therapeutic support and timely access to specialist input.

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

The service used multiple methods to gather feedback and ensure people were involved. Residents’ meetings, surveys and structured feedback processes were in place, giving people and their families opportunities to express views about their care. Where people did not attend group meetings, staff adapted their approach and sought feedback individually in ways that suited people’s communication needs.

Accessible information supported people to speak up. Easy‑read complaints and safeguarding materials explained how to raise concerns and who to contact, including external organisations. This helped people understand their rights and how to seek support if they were unhappy or felt unsafe.

Families confirmed they were able to give feedback and were kept informed. They described communication as clear and said managers responded to concerns and suggestions, demonstrating that feedback was valued and used to improve care.

Staff understood how to raise concerns and said they felt confident doing so. Clear processes were in place for escalation, and an open culture encouraged staff to contribute to improvements.

When something went wrong, the registered manager apologised to people and explained the actions they were taking to prevent this from happening again.

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 clear policies to promote equality, fairness and respect for all staff. These ensured equal opportunities across recruitment, training and development, and set expectations that staff worked in an environment free from discrimination, bullying or harassment.

Leaders promoted an inclusive culture that recognised and valued diversity within the workforce. Monitoring systems supported oversight of protected characteristics and helped ensure equitable practice and representation.

Observations showed staff worked within a diverse team and applied inclusive approaches in their practice. Staff recognised and respected individual differences, including cultural and religious needs, when supporting people and working with colleagues. This demonstrated inclusive values were embedded in day‑to‑day practice rather than limited to policy.

Leaders supported staff development and progression, with opportunities for staff to build skills and take on additional responsibilities. This contributed to a sense of fairness and inclusion, with staff supported to develop based on ability and potential.

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.

Leaders maintained clear governance arrangements with defined roles and responsibilities across the management team. Systems were in place to monitor performance, review care quality and ensure staff understood their responsibilities. Shifts were carefully planned with clear allocation of duties, supporting consistency and accountability in day‑to‑day operations.

Governance systems supported proactive decision‑making and service development. External professionals described the service as “collaborative, proactive and solution focused,” and said clear structures supported coordinated working and effective oversight of care delivery. Leaders ensured effective coordination across agencies, with professionals reporting roles and responsibilities were clearly understood and communication was consistent.

The provider demonstrated strong oversight of quality and risk. Systems for monitoring behaviour support, incidents and outcomes enabled leaders to identify trends and make improvements. Professionals confirmed the service sought advice early and acted on recommendations, supporting continuous improvement.

However, during the assessment, we identified that a statutory notification had not been submitted as required. Although the provider had completed all necessary internal documentation relating to the incident and contacted the local authority, they had not notified us in line with regulatory requirements. Following this, the provider took prompt action and submitted the notification. This demonstrated that while governance systems were established, they were not always used consistently to ensure full regulatory compliance.

Leaders also planned for long‑term sustainability. The provider maintained a clear vision to remain a stable, relationship‑focused service while continuing to develop care quality and outcomes. The governance arrangements supported safe, coordinated and sustainable care, although minor improvements were needed to ensure full regulatory compliance.

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.

External professionals described joint working arrangements as open, collaborative and effective. A behavioural specialist said communication and information sharing were “open and collaborative,” and that management were “responsive throughout the review process,” facilitating access to records, observations and discussions needed to support quality improvement.

Professionals reported that staff knew people well and shared information appropriately to support joined‑up care. One professional said staff showed “good awareness of physical health needs, dietary needs, and risks associated with residents’ care and support,” and “frequently demonstrated familiarity with residents’ communication styles and behavioural presentation.” This supported timely input from other services and early responses to changing needs.

The service proactively sought external input to improve practice. A behavioural specialist confirmed the provider commissioned an external positive behaviour support review as part of ongoing service development and quality improvement. Leadership were described as “open to feedback and motivated towards ongoing improvement,” with staff willing to engage reflectively in discussions about practice.

Professionals said the service engaged with multidisciplinary partners and made appropriate referrals where needed. There were no concerns raised about the timeliness of referrals or responsiveness when professionals contacted the service. One professional said communication from management was “timely and accessible” throughout their involvement.

Professionals also highlighted the service’s culture and values. One said staff interactions were “consistently respectful, supportive, and caring,” and noted a “strong commitment to community inclusion and personalised support approaches.”

Joint working supported coordinated care, continuous improvement and positive outcomes for people using the service.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always 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 demonstrated an exceptional commitment to learning, innovation and continuous improvement, embedding these principles across all areas of the service. Leaders actively sought opportunities to strengthen care delivery, improve outcomes and develop both staff and systems in response to people’s needs.

The service developed innovative practices to enhance care and governance, including the creation of a bespoke care records and management system tailored specifically to the needs of the service and the people it supports. Once the system is live, it will improve the quality, accessibility and oversight of care records, enabling staff to deliver more responsive, personalised care while strengthening real-time monitoring of outcomes, risks and performance.

Leaders invested in their workforce through a range of employee benefits and development opportunities, recognising the link between staff wellbeing, retention and high-quality care. They proactively sourced bespoke training packages aligned to the complex needs of people using the service, ensuring staff had the specialist skills and confidence required to deliver safe and effective support.

The provider worked in strong and purposeful partnership with external organisations, demonstrating leadership beyond the service itself. For example, they collaborated with a college to deliver adult care skills bootcamps, supporting workforce development both within the service and the wider community. In addition, the provider took a lead role in supporting complex transitions, working closely with professionals to ensure people experienced stable, well-planned moves and continuity of care.

Leaders embedded a culture of learning and improvement, which supported staff to reflect on practice and make consistent improvements to care delivery.

Following accidents, incidents and near misses, leaders ensured staff were supported through both individual and group reflective sessions, encouraging open discussion, shared learning and continuous improvement. Feedback from stakeholders was actively sought and used to drive changes in practice, demonstrating a proactive and responsive approach to improvement.

Leaders were highly visible and led by example, consistently modelling best practice, values and behaviours. This created a strong, positive culture where staff felt supported, motivated and empowered to contribute to service development and deliver high-quality care.

Innovative practice, strong partnerships and continuous improvement drove sustained improvements in care quality, staff capability and people’s outcomes. Bespoke systems, targeted training and proactive collaboration enabled the service to deliver consistently responsive, coordinated care, supporting better outcomes and increased independence beyond expected standards.