West Hampshire DCA

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 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 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 demonstrated an understanding of key values such as dignity, respect and independence, with 1 describing a culture where they “try to go above and beyond.”

Feedback reflected a positive and inclusive environment, where staff felt all levels worked together without hierarchy and with a shared purpose. Staff and leaders were aware of principles such as duty of candour. Leaders reinforced this through promoting openness and transparency in practice. Staff reported receiving regular updates and guidance following organisational changes, supporting a consistent approach to care and practice.

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. The service was overseen by 2 service managers who shared responsibility across multiple supported living settings, providing structure and oversight. A manager had recently been appointed and was currently undergoing the CQC registration process; once registered, this was expected to further strengthen leadership capacity and oversight across the service

Staff described leaders as organised and capable. One staff member said managers were “very well organised, they are on time and approachable.” Leaders also demonstrated a commitment to developing their capability, with 1 service manager undertaking a Level 5 qualification to strengthen their leadership knowledge and practice.

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

Staff described managers as approachable and responsive, 1 staff member told us, “Yes I know there is a whistleblowing policy and the service manager has a fairly open-door policy and I can go to them with any issues,” and another staff member said, “We don’t wait for meetings before we raise anything, they [managers] encourage us to raise anything, if we need them, they are aways available.”

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.

Staff spoke positively about the support they received, particularly during personal circumstances, with 1 explaining management were “really supportive” and operated an “open-door policy.” Others described how managers supported them through significant life events, including medical treatment and recovery, ensuring flexibility with shifts and a focus on wellbeing.

This approach demonstrated a caring and inclusive culture, where staff felt valued and supported. As a result, staff were able to continue in their roles with the support they needed, contributing to a stable and consistent workforce and positive outcomes for people using the service.

Governance systems were not consistently effective in assessing, monitoring, and improving quality and safety. Although audits and quality assurance processes were in place, these had not identified all concerns found during the assessment, indicating gaps in oversight.

Risk assessments and support plans had not always been reviewed in line with the provider’s guidance and gaps in key medicines documentation limited effective oversight. Outcomes within support plans were often broad and not clearly personalised and the provider’s governance systems had not identified or addressed this through audit or quality assurance processes.

This lack of effective oversight extended to Mental Capacity Assessments and Best Interest decision-making processes. Governance systems had failed to identify inconsistencies, delays, and limited detail within records, including where decisions were not clearly decision specific. As a result, opportunities to ensure records were robust, timely, and person-centred had been missed.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The provider and staff worked with a wide range of relevant internal and external stakeholders to support the provision of people’s care including provider specialist teams such as PBS, as well as local authorities and GP practices. One professional told us “Yes. We recently had a planning meeting and there was some actions identified from that meeting. A follow up of if the actions had been done by the provider will be looked at on the next planning meeting.”

The provider did not consistently focus on continuous learning, innovation and improvement across the organisation and local system. While the service had an action plan in place, it was not consistently updated or used to demonstrate clear and measurable progress. Although some tasks were completed, others remained partially complete, and in these cases the reasons for non-completion were not always clearly recorded. Additionally, some actions were completed after their due dates, indicating limited oversight and timeliness.

Although areas for improvement were identified, there was insufficient evidence of consistent review or follow-through to demonstrate that learning was embedded or led to sustained improvements. As a result, the provider could not fully demonstrate that learning, improvement and innovation were driving meaningful and measurable changes in practice.