Consensus Community Support - Surrey

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 since their registration in February 2024. 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.

Staff were supported to deliver high-quality, person-centred care in line with the provider’s values. Since taking up their role at the start of the year, the current service manager had made improvements to ensure staff received training, supervision, and access to relevant policies and procedures to support effective practice.

Through audits, team meetings, and supervision, managers monitored staff understanding of the provider’s values and how they were applied in practice, and recognised staff when they demonstrated them in their work.

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 current service manager was passionate and enthusiastic about their role and committed to ensuring that people at the service received high-quality, safe care. They were experienced and undertook continuous learning and development to maintain their skills and knowledge.

People and staff told us the service manager had made many positive changes since joining the service. A relative told us, “[Service manager’s] starting point was to get all the policies and processes in place, followed, and work from there. I have asked her about staff policies, and she has told me what I can expect…I think the management team will make lots of positive moves and they will work with us going forward too.” A staff member said, “[Service manager] comes in and chats with us and is more sociable. I think [service manager] wants the best for us. Now I feel happier and love my job.”

The service manager had been well supported by the provider to make improvements and changes at the service. They told us, “I have regular catch-ups with senior leaders and they check I’m okay. I also have a lot of support from the quality assurance team, HR and property services. The support is there, and it is really good to work for a company that provides this level of support.”

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

People were actively encouraged to share their views and experiences about the service through a range of methods, including key worker meetings, daily discussions, and feedback forms. Relatives felt comfortable raising concerns and felt listened to and asked for their views. Staff were supported and encouraged to raise concerns without fear of consequences. A staff member told us, “I feel much more confident speaking up about things. We’re always told to talk about anything that worries us.”

The provider had systems in place for feedback and concerns to be raised safely and acted upon.

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 were treated fairly and equally at work and received training to support their understanding of equality, diversity and inclusion. They were provided with opportunities for learning and development, with access to progression in their roles if they wished to pursue this. A staff member told us, “I would like to progress on in the future. I think the staff are all treated equally and fairly. The support is very good from the managers and they do assist.” The service manager said, “I treat people how I would want to be treated. I have had 1-2-1’s with staff to work out how they feel and issues they have and setting expectations. I make sure all the staff are aware of opportunities so that anyone that wants to progress, can. I also look at individual skill sets and sit with staff on how they can develop further.”

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 arrangements were in place to support the delivery of safe, high-quality and sustainable care. Managers carried out regular audits and checks of the service, using the findings to identify areas for improvement, implement necessary changes, and support staff to improve practice.

Managers demonstrated understanding of their regulatory responsibilities, including providing accurate information, ensuring appropriate support, and applying the duty of candour where required.

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.

Managers and staff worked in partnership with healthcare professionals to support the delivery of safe, high-quality care. They followed guidance and recommendations from external professionals to inform care delivery and improve practice. Managers used this collaboration to support staff learning and enhance the safety and quality of care provided to people.

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.

Since taking up their role at the start of the year, the current service manager had made changes at the service which people, relatives and staff recognised as positive and had led to demonstrable improvements in the quality of care and support provided. These included updating care records to better support care delivery, improving staff understanding of policies and processes, and boosting morale through stronger communication and clearer career development opportunities. They told us, “We put in place a service improvement plan and this has helped us to bring the service back up…The service is a vast improvement from where it was. Relatives have commented on how much things are improved and staff are happy, and people are going out more.”

The service manager also sought feedback from people, their relatives, and staff to support ongoing learning and improvement. This feedback, along with learning from incidents, audit outcomes, and quality checks, was used to drive improvements in the safety and quality of care and support provided.