Collegiate House

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 outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 96 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

Without exception, staff spoke highly of the management team and described leaders who were approachable, responsive and committed to both staff well-being and achieving the best outcomes for people. Staff told us they felt listened to, respected and valued, and were confident that suggestions and ideas would be considered and acted upon. A staff member said, “It is a good place. People are very well looked after, they get so many choices, people's well-being is cared for. They are the priority. The managers are very supportive, they listen, even to extent of caring about your personal life, they have a good listening ear for the staff and for the residents.”

We observed a calm, welcoming and homely atmosphere. Interactions between people, staff and leaders were warm, respectful and focused on promoting people's choice, independence and well-being. The culture of the service was consistently person-led, with people remaining at the heart of decision-making and daily practice. The provider had clear values and expectations which were understood by staff and embedded within the day-to-day delivery of care. Staff demonstrated a shared commitment to supporting people to live fulfilling lives and consistently placed people's wishes, preferences and aspirations at the centre of the support they provided.

Staff described morale as exceptionally positive and spoke about a strong sense of teamwork across the service. Effective communication was a key strength, with staff working collaboratively to ensure people received consistent, high-quality support. Robust handovers were completed at the beginning and end of each shift and included detailed information about people's health, well-being, moods, activities and any changes in presentation. This ensured staff remained well informed and able to respond effectively to people's needs. The shared vision between leaders and staff created a positive culture where people, relatives and professionals could be confident that care was delivered consistently, compassionately and in line with the service's values. As a result, people experienced a supportive environment where they were respected, empowered and enabled to achieve positive outcomes.

The provider had exceptionally 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 always did so with integrity, openness and honesty.

The service benefited from strong and effective leadership, with a clear management structure that was well understood by people, relatives and staff. Leaders were visible within the service and maintained regular oversight of people's experiences, well-being and the quality of care provided.

The management team undertook daily checks of the service to ensure people were safe, happy and engaged in activities and experiences that were important to them. This proactive approach enabled leaders to identify issues quickly, maintain high standards of care and ensure people continued to achieve positive outcomes.

People, relatives and staff consistently spoke positively about the leadership team. They described managers as approachable, supportive and responsive, and told us they felt listened to when raising ideas, concerns or suggestions. Staff and relatives were confident that leaders knew people well and had the knowledge and skills required to lead the service effectively. A relative said, “"We can't believe there is a place that can care for [name] so well. The ethos of the managers is exceptional...they'll do anything for [name]."

Leaders promoted an open culture where communication was valued and information was shared effectively. Regular meetings were held with staff and senior team members to discuss achievements, share learning and review any concerns, including safeguarding matters. Staff told us these meetings were informative and useful, and records demonstrated high levels of engagement and participation.

Staff spoke passionately about the support they received from leaders and the positive culture that had been established within the service. One staff member described the management team as “the best managers they have ever had.” This reflected the high regard in which leaders were held and the positive impact they had on staff morale, well-being and performance.

Through their visible presence, strong oversight and commitment to both people and staff, leaders had created a culture of openness, accountability and continuous improvement. This helped ensure people consistently received high-quality, person-centred care from a motivated and well-supported workforce.

The provider was exceptional at fostering a positive culture where people knew they could speak up and their voice would be heard. Without exception, those we spoke with told us they would feel comfortable speaking up and were confident any concerns or suggestions would be listened to and acted upon.

Leaders had created multiple opportunities for people to share their views and influence the development of the service. An open-door policy was in place, and people were encouraged to speak with managers whenever they wished. Regular care reviews, staff meetings and feedback surveys provided further opportunities for people, relatives and staff to contribute their views and experiences.

Staff described a supportive culture where they felt able to raise concerns without fear of negative consequences. They told us managers were approachable, listened to feedback and took appropriate action when issues were identified. This helped create a culture of openness, transparency and continuous improvement.

At the time of our assessment, the service had not received any formal complaints. However, systems and processes were in place to manage complaints effectively should they arise. The registered manager demonstrated a clear understanding of their responsibilities in relation to receiving, investigating and responding to concerns in a timely and appropriate manner.

The service regularly received compliments from people, relatives and professionals, reflecting the positive experiences of those using the service. Feedback included, “A big thank you to staff for all your hard work”, “I was so impressed with the staff’s person-centred approach” and “Thank you so much for all you do, it means the world to me and my family”

The positive feedback received, combined with the confidence people, relatives and staff expressed in speaking up, demonstrated a culture where individuals felt valued, listened to and empowered to contribute to the ongoing development of the service.

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them. Leaders recognised that individual staff members may require different approaches to support and worked proactively to ensure reasonable adjustments were made where needed. For example, the management team had worked closely with a staff member who had a disability, adapting the way instructions and information were provided to meet their individual needs. This personalised approach reduced the staff member's anxiety, increased their confidence and contributed to improved performance in their role. This demonstrated the provider's commitment to supporting staff to achieve their full potential.

The service benefited from a diverse workforce and promoted inclusive recruitment practices, including employing staff through sponsorship arrangements. Leaders recognised the value that different backgrounds, experiences and perspectives brought to the service and actively fostered an environment where everyone felt welcomed and respected.

Without exception, staff told us they felt included, valued and able to contribute their views. Staff described a positive culture where their voices were heard and where leaders treated people fairly and with respect. No staff reported experiencing discrimination, bullying or unfair treatment, and all said they felt appreciated for the work they undertook. Staff feedback surveys reflected high levels of satisfaction and engagement. Comments included, “Team spirit is top notch”, “I enjoy how the team works together” and “I like how inclusive and person-centred it is”. These responses demonstrated a strong sense of belonging and a workforce that felt supported and empowered.

As a result, the service had developed an inclusive culture where diversity was valued, equality was promoted and staff felt respected and supported to thrive. This positive culture contributed to high staff morale and helped ensure people received care from a motivated, compassionate and engaged workforce.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Robust governance systems were in place to monitor the quality, safety and effectiveness of the service. Leaders maintained clear oversight through a comprehensive 'Good Governance' calendar, which detailed audit schedules, compliance levels and forthcoming quality assurance activity. This enabled the management team to identify trends, monitor performance and ensure people continued to receive safe, high-quality care and support.

A wide range of audits were completed to assess the safety and quality of the service, including health and safety, infection prevention and control, medicines management, care records, dignity and respect, and people's experiences of care. Audit findings were analysed and used to drive continuous improvement across the service. Where improvements were identified, clear action plans were developed and closely monitored by leaders. Records demonstrated that actions were completed promptly and effectively, reducing risks and improving outcomes for people. This proactive approach ensured issues were addressed before they had a significant impact on people using the service.

Leaders also maintained effective oversight of workforce performance and development. Staff received regular supervision, annual appraisals, competency observations, spot checks and knowledge assessments. These processes enabled leaders to monitor staff practice, identify training needs and provide support to promote both professional development and well-being.

Governance systems were used not only to monitor compliance but to continually enhance people's experiences and quality of life. Information gathered through audits, reviews, incidents, feedback and staff performance monitoring was used to inform service improvements and promote positive outcomes for people. A professional said, “The majority of my contact has been with management at the service. They have been available for discussions at every visit. They have presented as knowledgeable about the individual in question and open to joint working. They have reliably attended all meetings in relation to this individual, including weekly MDT meetings, which strictly speaking, there was no obligation for them to do. They attended these meetings with the intention to improve the day-to-day care and conditions for the individual in question.”

The management team demonstrated a clear understanding of their regulatory responsibilities and the principles of Duty of Candour. Notifiable incidents were appropriately reported to relevant agencies, and leaders promoted an open and transparent culture where learning was shared, and improvements were embedded into practice.

As a result, governance arrangements were highly effective in maintaining high standards, driving continuous improvement and ensuring people consistently received safe, person-centred care that achieved positive outcomes.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement. Staff had developed strong and effective partnerships with relatives, professionals and community organisations to ensure people experienced meaningful opportunities and achieved positive outcomes. A relative said, “We work with community learning disability nurses, the psychiatrist and the team. We are all working together.” Without exception, relatives and professionals spoke highly of the service and described it as exceptionally well led. Feedback consistently highlighted the commitment of staff and leaders to going above and beyond to meet people's individual needs and aspirations.

Staff were passionate about promoting community inclusion and worked proactively to ensure people remained connected to their local communities. People were regularly supported to access community facilities and pursue their interests, and during our inspection we observed people enjoying visits to local parks, zoos and hairdressers. These opportunities helped people develop confidence, maintain community connections and participate in activities they valued.

The provider actively created opportunities for people to develop social networks and build relationships beyond their immediate home environment. Regular events were organised across the provider's services, including weekly football and basketball sessions, enabling people to meet others with shared interests and develop lasting friendships.

Staff also supported people to access new experiences and opportunities. For example, people recently enjoyed a holiday to Cornwall, where the provider had worked closely with a local campsite to ensure inclusive activities were available and accessible. This demonstrated the provider's commitment to removing barriers and enabling people to fully participate in community life.

These opportunities had meaningful and lasting outcomes for people. For example, one person developed a friendship whilst on holiday and had exchanged friendship bracelets with their new friend. Staff supported them to maintain contact following their return home, helping to sustain an important relationship and promote their emotional well-being.

People's achievements, experiences and relationships were celebrated and valued. People kept photographs and memorabilia from special events and experiences, helping them reflect on and share positive memories. We saw videos of people surfing during their holiday in Cornwall, which people enjoyed watching and reminiscing about with staff and friends.

Through strong partnership working and a commitment to community inclusion, the service supported people to build meaningful relationships, access new opportunities and enjoy experiences that enhanced their well-being, independence and quality of life.

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. Leaders demonstrated a strong commitment to continuous learning and improvement, with a clear focus on enhancing people's quality of life, well-being and experiences of care. Improvement activity was driven by a desire to achieve better outcomes for people and ensure support remained person-centred, innovative and responsive to changing needs.

Robust systems were in place to monitor, evaluate and improve the quality of the service. Outcome trackers were used to measure progress against people's goals and aspirations, enabling leaders to assess whether support was achieving the outcomes that mattered most to people. This formed part of a wider continuous improvement cycle, which encouraged staff to reflect on practice, identify opportunities for development and celebrate achievements.

Regular quality assurance visits were undertaken and used to identify areas for further improvement. These reviews focused on people's experiences, outcomes and quality of life, helping leaders to ensure the service continued to evolve in response to people's changing needs. For example, following improvements in one person's emotional well-being and a reduction in incidents of distress, staff supported them to work towards spending more time with loved ones at home, helping them achieve an outcome that was important to them.

Leaders gathered information from a variety of sources, including feedback surveys, reviews, staff meetings, audits and day-to-day observations. Findings were analysed and translated into action plans, with progress monitored through a comprehensive quality improvement plan. This ensured learning was embedded into practice and improvements were sustained over time.

The quality improvement plan evidenced a proactive approach to enhancing people's experiences. For example, the provider had identified and implemented a dedicated arts and crafts area in response to people's interests and was exploring further opportunities to strengthen staff supervision and development processes. This demonstrated a commitment to improving outcomes for both people and staff.

Improvement activity consistently focused on achieving meaningful outcomes for people. Records evidenced numerous examples of positive changes, including people achieving weight-loss goals, reductions in incidents of distress and individuals gaining greater control over their finances and day-to-day decision-making. These improvements were celebrated and used to inform future planning and development.

As a result, the service had established a culture of continuous learning and improvement, where feedback was valued, innovation was encouraged and outcomes for people remained at the heart of service development. This approach enabled the provider to continually enhance the quality of care and support people to live healthier, more independent and fulfilling lives.