Sunderland

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 inspection for this service. This key question has been rated good. This meant the service management and leadership were consistent. Leaders and the culture they created supported the delivery of high-quality, person-centred care.

This service scored 68 (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 and leaders demonstrated a listening culture and were open to learning and improvements. A relative commented, “The service will do well if all staff have same ethos as the registered manager.” Equality and diversity within the service was promoted. New staff received support and training which helped them to show those values in their daily work with people. A staff member told us, “The registered manager treats people and staff very well, if staff are happy and respected, people will be happy too.”

The service 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 provider demonstrated they had the skills and knowledge to manage the service effectively with support from the directors. Staff members’ comments included, “It is the best organisation I have worked for”, “I love working here” and “The manager is very approachable and supportive.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Processes were in place for staff and people to speak up. The provider had a clear whistle blowing policy. Staff could raise concerns and the information about how to do this was available in the staff handbook. Staff meetings took place, and staff had the opportunity to share comments and give feedback. People were informed of the complaints procedure when they started to use the service. A staff member told us, “We have staff meetings and are asked for our feedback.”

The provider valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff provided positive feedback about their experience of working at the service and told us they felt equally treated and supported by leaders. They told us they felt valued and respected in their roles. They said they felt supported by the management, some said they were well supported in personal matters, when needed. A staff member commented, “If you need to change a shift because of personal commitments, the registered manager is very responsive and caring.”

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 share this securely with others when appropriate. There was oversight from the provider to review the quality and safety of the service in line with regulatory requirements, with quality checks carried out. However, some audits such as around care records medicine management and other areas identified during our inspection needed to be more robust.

Staff at the service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. Staff worked alongside other professionals to ensure appropriate support was provided. The provider attended network meetings with the local authority and other providers to share best practice.

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. Staff and leaders had a good understanding of how to make improvement happen. Leaders encouraged staff to speak up with ideas for improvement. Processes to ensure that learning happened when things had gone wrong, and from examples of good practice were well-established. There was evidence of changes that had been made to the service to make improvements and to address checks and audits outcomes and in response to people and staff feedback. However, we identified further improvements were needed in areas as described within the report.