CSL Spilsby

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 71 (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 demonstrated a clear understanding of the organisation’s vision and values. There was a consistent view that both staff and leaders embodied these principles in their daily practice. Leadership was visible and accessible, and there were established policies and frameworks in place to support the promotion and integration of these values throughout the service.

The provider had inclusive leaders 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. A new manager had recently been appointed, and staff reported that efforts were being made to enhance wellbeing and strengthen team cohesion. This contributed positively to the overall culture of the service.

Managers fostered a positive culture where people felt they could speak up and their voice would be heard. The provider actively worked to prevent a closed culture. Staff felt confident in raising concerns and sharing ideas and were familiar with the whistleblowing policy. Regular meetings provided opportunities for staff to give feedback directly to leadership, which was valued and acted upon.

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. Fair treatment and the celebration of diversity were prioritised by the provider. The manager demonstrated flexibility in managing workloads and rotas to support the needs of both people using the service and staff. This approach promoted inclusivity and respect within the team.

The provider had clear responsibilities, roles and quality assurance systems in place, but the quality of records was inconsistent. Records of outcomes of care and achievements along with the consistency of guidance for staff about person led approaches required development. The current records repeated the same generic statements in different ways rather than specifying exactly how to support a person to achieve their goals and aspirations. There were also inconsistencies in how feedback from people and relatives were recorded, which limited the ability to evidence and track improvements over time. The provider was proactive and had identified these areas for improvement and had development plans underway, but these were not yet implemented or embedded. Leaders acted on the best information about risk and shared this securely with others when appropriate. Systems were in place to ensure accountability and promote safety. Regular audits were conducted with transparent reporting, and action plans were shared across teams. The provider communicated expectations clearly and had a strategic approach to improving the quality of care.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning and worked together with external organisations to drive improvement. Feedback from other professionals the positive working relationships maintained by the service and professionals had no concerns about the service.

The provider focused on continuous learning and improvement across the organisation and local systems. There was a strong commitment to continuous improvement from both the manager and the wider leadership team. Staff were encouraged to contribute ideas for service development and were supported in accessing learning opportunities to enhance their skills and knowledge.