Leys Consultants

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 requires improvement. At this assessment the rating has changed to 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. An open and honest culture had been created, where staff, people and relatives were encouraged to speak up and express their views and opinions. The management team focused on providing person centred care which met people’s individual needs. As the service was small, the management team knew each person well and were in regular contact with them to ensure the service continued to meet their needs.

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. A registered manager was in post and a clear management structure was in place that provided leadership across the service. Staff had allocated supervisors but were welcome to approach any of the leadership team if they had questions or needed advice. Staff understood their role and responsibilities, including the registered manager and the requirements of their CQC registration. They submitted statutory notifications about key events that occurred at the service as required.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. A whistleblowing policy was in place and staff were encouraged to speak up. The service did not have a freedom to speak up guardian nominated and due to the small size of the company, it was difficult to have someone in this independent role. However, the care workers had been encouraged to develop peer support processes, and one care worker had been nominated to speak up and meet with the management team to advocate for any staff issues.

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 supported professionally and personally. The management team took account of staff’s individual needs and provided any support required, including flexible working for staff with personal commitments and if they wished to have time off for special occasions. Staff were supported to continue with their religious practices and supported to have regular breaks to pray if they wished to. The management team protected their staff from abuse and did not tolerate any forms of discrimination.

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. The management team undertook a regular programme of spot checks to review the quality and safety of care delivery. This enabled them to observe hands on care and interactions between care workers and the people they were supporting to ensure this was in line with the provider’s policies and procedures, and met people’s needs. The manager regularly reviewed daily notes to review call log data, compliance with call times and completeness of records. Processes were in place to review key service data, including any incidents, accidents or complaints received to ensure they were learnt from.

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 management team worked in partnership with people, relatives and staff. There were regular telephone calls to people and their relatives to obtain their views about the service, as well as completion of satisfaction surveys. At the time of our assessment the phone calls were an informal process and were not documented, but the registered manager told us they hoped to formalise these processes to ensure clearer documentation and follow up if any concerns were raised. There were regular staff meetings and supervision sessions where staff were asked for their views and opinions. A staff member said, “We do speak up in those meetings and we always raise any issues if we have them.” The management team also regularly liaised with partner agencies, including the funders of people’s care and other care providers.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. The registered manager regularly met with other care providers and attended the local authority care provider forums, to share ideas and gain advice. During these meetings best practice guidance was discussed which was used to help inform care provision. At the time of our assessment, an improvement plan was not in place but the registered manager told us they continued to focus on providing high quality care that met people’s needs and ensured their workforce were well trained and supported.