Sanctuary Oasis Ltd

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 it was registered on 16 May 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.

The provider’s mission was aimed to be ‘the best partner for the clients and organisations we work with.’ The registered manager was committed to these values and promoted a person-centred culture focused on achieving positive outcomes for people. Staff understood these values and expectations which were regularly reinforced through team meetings.

An open and transparent culture was supported by clear strategies, policies and procedures. Staff spoke positively about the service, describing good teamwork, leadership and a shared commitment to person-centred care. They told us they received the support and guidance needed to perform their roles effectively and communicated well with leaders.

The registered manager was passionate about improving people’s quality of life. One person told us, “I think the service is managed well, I normally contact [Staff name] if I need anything and usually email instead of telephoning. I find them responsive.”

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 provider was also the registered manager. They kept their knowledge up to date, ensuring the service followed current best practice, standards and regulatory requirements, including notifying CQC as required by law. They also recognised the importance of continuous professional development and had systems in place to support both their own learning and reflective practice, as well as the training and development of staff. This demonstrated a commitment to effective leadership, continuous improvement, and maintaining high-quality care that met people’s needs.

Staff told us leaders at the service were helpful and kind. Comments included, “The office staff me very well. I call them for advice or to report a problem and they'll help and guide me what to do” and “If need to make changes because of appointment, it's managed by the office.” Some feedback indicated that rota changes were not always communicated promptly. The provider told us that unplanned staff sickness and emergencies could sometimes lead to last-minute changes, and they were working to improve communication with people, relatives, and staff.

People and relatives spoke highly about the office staff and the registered manager. One relative told us, “I do not have any problems when I contact the office, I just email or text [Registered manager name] or [Care coordinator name] and they will do something about it. [Named care coordinator, field supervisor, and team leader] are fantastic; they always listen to me and reassure me.”

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

Staff had regular meetings which were conducted openly and encouraged feedback. Staff felt leaders were approachable and felt listened to.One staff member told us, “No concerns about my colleagues’ practice but I would say something if I thought that they were doing not it right.” However, some staff felt their concerns had not been fully addressed. The provider told us that all concerns were considered, although at times the outcomes did not always meet staff expectations.

The provider did not currently have a Freedom to Speak Up Champion but was exploring introducing the role. In the meantime, staff were encouraged to raise concerns with their supervisor or office staff.

The provider had a whistleblowing policy in place which informed staff how to raise concerns. System was in place to support staff to speak up and raise concerns relating to the care of people and the running of the service. One staff member described a culture where concerns were raised promptly and acted upon in line with policies and procedures to support people’s wellbeing.

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.

The provider promoted a safe, supportive and inclusive working environment. Staff told us they felt respected, valued and able to raise concerns. One staff member told us, “I've always been treated fairly and equally by my colleagues and by management.” Another staff member said, “As a sponsored staff, I do feel part of the team and I’m supported by management.”

Staff had received equality and diversity training and felt they were treated fairly and without discrimination. The provider promoted equality and diversity, offered opportunities for staff development, and supported flexible working arrangements to help balance personal commitments and appointments.

The provider had clear governance and accountability arrangements in place to deliver safe, high-quality care. They used information about risks, performance and outcomes to monitor the service and share information appropriately when needed.

The provider had governance systems in place to monitor the quality and safety of the service. These included regular spot checks, competency assessments, and audits of areas such as health and safety, care plans, daily records and staff files. While we identified some risk assessments that combined multiple risks and contained limited or irrelevant control measures, this had not been identified through the provider’s own monitoring processes. The provider was receptive to our feedback and took prompt action to address this.

As the provider transitioned to a digital care system, monitoring and scrutiny of records needed further strengthening. We identified inconsistencies in medicine recording and found some unresolved alerts relating to missed or unlogged visits and incomplete care tasks. We found no evidence that people had come to harm. The provider responded positively to our feedback and took prompt action to address the issues identified.

The provider used feedback to identify and drive improvements. For instance, analysed surveys along with incidents, complaints and compliments to draw learning and make changes to the service.

Systems were in place to ensure staff were suitable for their roles, received up-to-date training, and communicated effectively across the organisation. This helped ensure people received safe, effective and well-managed care.

Policies and procedures were in place to support the delivery of safe and effective support. All documents were regularly reviewed and reflected current guidance as required. A business continuity plan was in place which included information about contingency plans in the event of an emergency.

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 and management team told us they worked in partnership with other agencies to provide support to people. They included the district nurse, GP and other health professionals as well as the local authority to provide people with appropriate care and support people needed. Records showed evidence of effective collaboration with professionals and families.

Feedback from professionals was positive and reflected effective partnership working.The local authority who has responsibility for monitoring the care for people they supported told us the service had achieved the required standard of care expected.

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.

The provider recorded and analysed incidents, accidents, and safeguarding concerns to identify trends and improve care. Learning was shared with staff through training and team meetings, which were also used to reflect on incidents and identify areas for improvement.

Leaders and staff worked collaboratively to drive continuous improvement. The registered manager welcomed feedback during the inspection and acted on it promptly. They maintained their knowledge through ongoing learning and attended forums and local authority meetings to share best practice and improve outcomes for people.