Advantage Healthcare West Midlands

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.

At our last assessment we rated this key question Good. At this assessment the rating has remained 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.

The provider had a clear set of organisational values centred on “community, courage and heart”, which were reflected throughout the service. Staff wellbeing, recognition and engagement were actively promoted through a range of initiatives including staff awards, wellbeing support, recognition schemes and opportunities for feedback.

There was evidence of a positive and open culture, with managers demonstrating a willingness to listen, learn and respond to concerns. Throughout the assessment, leaders were transparent, responsive and receptive to feedback, providing assurance that improvement remained a key focus.

Learning and improvement were embedded within the organisation through quality audits, provider learning feedback, improvement plans and regular communication with staff. The provider also actively sought feedback from both staff and people using the service to help the service development.

Feedback from relatives told us there had been recent improvements in leadership, responsiveness and communication. However, some families reported changes in managers and staff had affected their confidence in the service and led to inconsistent experiences.

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.

Leaders demonstrated a positive, open and supportive approach throughout this assessment. Managers were responsive to feedback, transparent in their discussions and willing to reflect on identified areas for improvement. There was clear evidence of leadership oversight through audits, improvement plans, team meetings and compliance monitoring.

The registered manager and leadership team promoted a culture focused on safe, person-centred care and supporting staff to deliver positive outcomes for people. Staff had access to clinical support, supervision, training and wellbeing initiatives, demonstrating a commitment to developing and supporting the workforce.

There was also evidence leaders listened to feedback and used learning from incidents, complaints and quality assurance activity to drive improvements across the service.

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

The provider had systems in place to encourage open communication and the sharing of concerns.

There was evidence of an open culture where concerns and incidents were discussed and acted upon. Learning from safeguarding concerns, complaints, medication incidents and quality assurance activities was shared across the organisation, demonstrating a willingness to reflect on practice and make improvements.

The management team were approachable and responsive throughout the assessment. They were open to challenge, receptive to feedback and took immediate action to review concerns raised during the inspection process.

The organisation also promoted engagement through staff feedback initiatives, communication platforms and wellbeing support services, helping to ensure staff felt valued and listened to.

Staff were aware of how to whistle blow and felt confident to do so.

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.

Management evidenced they promoted equality, diversity and inclusion through policies, recruitment practices and their approach to person-centred care. Systems were in place to ensure people could access information in ways that met their individual needs, including the use of translation services and accessible communication formats.

Care planning considered people's individual backgrounds, preferences, communication needs and circumstances, helping to ensure care was delivered in a respectful and inclusive manner. Staff were supported to provide personalised care that recognised and responded to differences between individuals.

The provider also promoted an inclusive culture for staff through wellbeing initiatives, engagement opportunities and recognition programmes.

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.

Governance systems were not always effective in identifying and addressing issues at an early stage. For example, medication audits had not identified some of the recording discrepancies found during this assessment. Furthermore, improvement plans and supervision records did not consistently demonstrate completed actions, timescales or evidence of outcomes achieved, limiting the provider's ability to evidence the impact of improvements.

Audits had failed to identify inconsistencies between prescribed administration times and administration records. We also found examples where supervision records and improvement plans did not consistently evidence actions taken, timescales for completion or follow-up arrangements. This meant leaders could not always demonstrate the effectiveness of actions taken to improve the service.

The provider had governance systems to monitor quality, safety and performance across the service. These included audits, improvement plans, provider learning feedback, team meetings and oversight from senior leaders, including the Head of Quality and Head of Compliance.

Learning from incidents, complaints and safeguarding concerns was shared across the organisation to support continuous improvement as a whole provider.

There was evidence of management oversight and a commitment to improving services.

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 provider worked in partnership with people, families, healthcare professionals and external agencies to support the delivery of safe and effective care. Records reviewed showed involvement from nurses, case managers, multidisciplinary teams and commissioners, particularly for people and children with complex health needs.

Families were involved in assessments, care planning and reviews, helping to ensure care reflected individual needs and preferences. Positive feedback from relatives, highlighted examples where staff had built trusting relationships with families and worked collaboratively to support positive outcomes for people receiving care.

The provider also demonstrated a commitment to building wider community connections. Organisational initiatives included partnerships to develop training opportunities, staff engagement programmes and recognition schemes which promoted a positive culture and strengthened workforce development.

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 provider demonstrated a positive culture of learning and continuous improvement. Systems were in place to review incidents, complaints, safeguarding concerns and audit findings, with learning shared locally and across the wider organisation to improve practice and reduce the risk of recurrence.

There was evidence of regular communication with staff, including medicines safety notices, clinical updates and lessons learnt from incidents. An internal improvement plan process was in place, enabling organisational learning to be translated into branch-level actions, with oversight from the Head of Quality and Head of Compliance.

The provider also utilised provider learning feedback and performance data to identify trends and areas requiring improvement. Concerns were investigated, learning was identified and, where required, additional guidance or support was provided to staff.