Channel Court, Sugar Lookout

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the service’s first assessment. This key question has been rated good. Leaders and the culture they created assured the delivery of high-quality 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. The provider had clear organisational aims, ‘to deliver exceptional, person-centred care that empowers individuals to live fulfilling lives with dignity and independence.’ These were underpinned by 6 values. The vision and values were described on the providers’ website and through the induction programme. A staff member told us the induction included, “The ethos of the company and values.” Staff spoken with gave examples of how they reflected these aims in their work with people. A staff member said, “Care is very person centred.” The provider had recognised where improvement previously had been needed in the culture of the organisation and made changes to roles and responsibilities to address this. Comments from staff included, “It took a while to get defined roles in place,” and “It is improved on but could continue to improve."

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Accidents and incidents were reported and recorded. Staff we spoke with knew the procedures to follow. A staff member said, “We have the incident reports in the system, we have to put a detailed description before, during and after. We are debriefed and they have their procedures they follow and go in depth on analysis.” Accident and incidents were analysed and reviewed for patterns and trends and recommendations taken forward. The provider acknowledged where improvements could be made to simplify their systems and tracking of incidents.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Systems were in place to enable staff to speak up such as regular staff meetings, supervisions and through surveys. Staff told us they could raise any issues. A staff member said, “Staff have to be able to voice any concerns.” Staff told us they knew about and had access to the whistleblowing policies.

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 an up to date equality and diversity policy. A staff member said, “Equality and diversity, it is promoted. There is no discrimination anywhere.” Staff told us they worked well as a team. A staff member said, “We definitely work well together. We are all different.” Another staff member said, We have a really good dynamic, everyone’s willing to help and support each other."

The provider had clear responsibilities, roles and systems of accountability, governance systems were in place. The service was delivering services to children that fitted the definition of a children’s home as described by the Care Standards Act 2000. This meant these services fell outside the scope of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and were in effect, unregistered services. Leaders were open and aware these services should be registered with Office for Standards in Education, Children's Services and Skills (Ofsted) and had taken steps to address this by reducing the number of packages of care of this nature and registering with Ofsted for 2 people. We took action to notify Ofsted of the other packages of support.

Roles and responsibilities had been revised and there was a clear staff structure. A staff member said, “We have placement managers and [Name of manager] as a regional contact. I know the hierarchy and where to go.” However, relatives we spoke with were not always clear of staff roles in the organisation. Comments included, “I don’t know who is in charge,” and “I don’t know who the manager is.”

Audits of the service were completed in areas such as infection prevention control (IPC), medicines and care planning. The provider completed regular checks and a service improvement plan detailed areas of development. Actions identified from audits and feedback received from family members were not always clear in how they had been monitored for progress or completion. Notifications were submitted as required to CQC.

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 service had worked to develop partnerships with local authorities and other stakeholders to respond to local support needs. A health and social care professional said, “We consider them be a trusted provider.” The service regularly liaised with other professionals involved in people’s care. A health and social care professional said senior staff at the service were, “Responsive and helpful.”

The service supported people to access and be part of their local community. Initiatives encouraged people to give back to the community. For example, by contributing to food banks and donating gifts at Christmas. The provider also supported a national charity which supported children and families.

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 looked to improve and reduce incidents. A staff member said, “We will sit down, find out what happened, what could have been done better.” Themes identified were communicated to staff with the actions taken. For example, training modules were adjusted.

The service supported staff in their career development and qualifications. For example, a staff member told us about their NVQ qualifications being facilitated and another staff member about internal role promotions. A staff member said, “They [the provider] support staff growth.” Staff were valued and recognised for their contributions through a scheme which distinguished when people had gone above and beyond. A relative said, “I can’t thank them [staff] enough for what they do.”

Surveys were completed with people, relatives and stakeholders. Actions taken were fed back. For example, through you said, we did information.