Head Office

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 75 (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 registered manager explained that the vision and ethos of the service were discussed during staff member’s inductions to ensure they understood them. Staff received training in equality, diversity and inclusion.

This service is required to have a registered manager. A registered manager is a person who has registered with the CQC to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection, the service had a manager who was registered with the CQC.

The registered manager explained they had an open door policy and actively encouraged staff to discuss any ideas or concerns with them. They had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

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

There were systems in place to support people and their relatives to feedback on their experiences of the service. This included care plan reviews and the complaints process.

There were opportunities for staff to speak up and share concerns and ideas. This included formal supervision meetings and direct contact with the registered manager.

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 received training in equality, diversity and inclusion. Staff were actively encouraged to share concerns and ideas.

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 in place to support the monitoring of the quality of the service and identify areas for improvement. These included health and safety audits, accident and incident reporting, safeguarding and complaints reviews and safe medication management.

Staff’s training was monitored by the registered manager to ensure staff’s knowledge and skills were up to date.

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 did not currently work in partnership with other agencies but understood they would need to do this as they took on more packages of care. The registered manager acknowledged the importance of working in partnership with others to ensure people received consistent care.

The provider had systems in place to ensure learning happened and changes to care were implemented when needed, to support good outcomes for people.

There were systems in place to ensure lessons were learnt from accidents, incidents and safeguarding concerns. Staff understood their responsibilities to raise concerns and record and report any accidents or incidents.

There were opportunities for staff to discuss any issues or concerns about the service during 1:1 supervision meetings.