DLS SW England Regional 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 newly registered 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 told us it was important to have an open culture in the team were everyone was working towards a common goal and staff were encouraged to raise any concerns they may have or make any suggestion to improve the service. Staff we spoke with told us they had no fear about speaking up and make suggestions. The management team were open to making improvements and committed to providing quality care for people.

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 registered manager had the skills and experience needed to manage the service. They had an open-door policy and staff told us they could speak to them at any time. Staff told us they felt valued and supported by the managers.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There were whistle blowing procedures in place for staff guidance if needed. Staff told us there were no concerns about speaking up. Staff told us if there was a concern they would take it to the management or out of the organisation if needed. Staff told us they did not have any fear of consequences.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There were whistle blowing procedures in place for staff guidance if needed. Staff told us there were no concerns about speaking up. Staff told us if there was a concern they would take it to the management or out of the organisation if needed. Staff told us they did not have any fear of consequences.

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 robust and effective. Quality frameworks included audits, staff observations, customers and family feedback, safeguarding oversight, complaints and incident monitoring, lessons learned, reflective practice, and staff development. Every aspect of care delivery was checked to ensure standards were maintained. Staff understood their role and what they needed to do to make and maintain improvement. Actions were recorded and where shortfalls were identified they were addressed without delay. For example, audits revealed occasional late visits during morning calls. As a result, rota planning and travel allocations were reviewed and adjusted. A follow-up audit was conducted over the following 2 weeks, which showed a significant reduction in late visits and improved punctuality across the service, demonstrating how the quality assurance system was used effectively to identify trends, implement corrective actions, and drive continuous improvement in the reliability and quality of care delivery.

Follow-up checks with people confirmed that punctuality had improved. In another example, a safeguarding concern was raised by staff and picked up in the quality system. This meant it was completed quickly and as a result additional measures were put in place for a person who was at risk of neglect. The provider shared several examples of how the auditing and governance system was used to improve people’s lives and the service overall.

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 with a range of organisations. These included the local GP, hospital discharge teams, health care professionals, the pharmacist, social prescribers and had links in the charity sector. The provider shared multiple examples of collaborative working in the community and local medical teams. The registered manager told us how this approach was assisting people in numerous ways and improving service for people overall. For example, supporting people to access community resources such as services for people’s mental health and well being. In another example, the provider also collaborated with a charity to organise transport for a person who was attending hospital appointments. In addition, the provider liaised with the local community and obtained additional support for a person who was new to the town. There were many other examples of how the provider had gone above and beyond their role in this area and the impact this had on people was significant.

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 had plans for improving the service and the quality of care for everyone they supported. There was a learning and improvement culture within the service. Quality meetings were held regularly and all the actions from the quality framework were discussed and implemented. People’s lives were noticeably impacted by the improvements in a positive way. Everyone we spoke with told us that overall, they were happy with the care being provided by the service.