Re-Create Freedom

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.

Staff were advised of the ethos of the service during their induction period. The registered manager told us they were looking at ways of delivering staff meetings, as there were difficulties getting the whole staff team together, with them also working in the provider’s day service and other care home. They were hoping the development of the team leader role would support this, with the possibility of having smaller group meetings.

We received mixed feedback regarding if staff felt they were empowered to make suggestions to improve the service. The registered manager told us they were open to suggestions to improve the service, and we were reassured improvements were ongoing with how staff could share their views, such as in supervisions.

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.

The registered manager was supported by a deputy manager and a team of team leaders. The team leader posts had recently been introduced, due to the service growing in demand. The team leaders would be supporting reviews of care plans, staff supervision and meetings, as the service was expanding and the registered manager was supporting this.

The registered manager had achieved a qualification relevant to their role. They told us they felt supported by the provider. The registered manager was committed to ensuring people using the service were provided with good quality care.

Relatives told us they felt the service was well led. A relative said, “[Management team] are so extremely lovely, easy going and really flexible… they are always accommodating and very well organised… [Registered manager] is so caring, nurturing, encouraging, and really genuinely interested in all the people in [their] care.”

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

There was a whistleblowing procedure in place and staff told us they would report concerns of bad practice. Staff were aware of their roles in reporting concerns and how to do this, including escalating them to senior management.

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 service had a diverse staff team. Staff had received training in equality and diversity. Staff told us they worked well together. A staff member said, if there were any issues between staff, they were quickly resolved.

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.

There were systems in place to monitor the service provision, which supported the management team to identify shortfalls and address them. The registered manager informed the provider of changes within the service and the outcomes of the monitoring of the service, including analysis of incidents.

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 told us they worked in partnership with commissioners and people’s relatives to meet people’s needs. A relative told us, “Communication is good, we are singing from the same hymn sheet, good and supportive strategies, they are not dismissive.”

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 service was growing in demand from registration, and the provider had opened another respite service. The registered manager told us there were systems for continuous learning and improvement as they grew. This was confirmed in the records to demonstrate monitoring and ongoing improvement.