Comprigney Vean

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 good. At this assessment the rating has changed to outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 89 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The provider promoted a positive and inclusive culture which put people at the centre of their care. Some of the staff we spoke with had worked with Green Light for several years in various services. They told us the organisational values were apparent across services although each home was different. One commented, “They are all different because there are different people living there. The values though are the same.”

Within the staff team there was a clear culture of supporting the person to lead a full and meaningful life in their local community. They told us they all worked for the same outcome and had shared values. This approach had led to positive outcomes for the person. The registered manager told us, “[Name] wasn't able to learn skills because they didn't have access (to the community). [Name] needs to do it to learn it. Now it’s much more about taking positive risk, learning from it and listening to [Name].”
There was an emphasis on the importance of staff building a positive, trusting relationship with the person. This was evident in our observations. We saw the person was relaxed with their staff team and turned to them for reassurance.
The provider was aware of the risks of closed cultures developing, particularly in single person services with a small staff team. The registered and deputy managers worked across 2 services, which minimised the risk of them becoming isolated. The registered manager received regular supervision and senior staff visited Comprigney Vean regularly. Policies covered how to support staff who were in a close personal relationship. Managers meeting were held every other month. These were an opportunity to share experiences and success stories. Managers shared on call duties across the organisation, this led to an ethos of shared responsibility and required managers to develop a working knowledge of other services. The registered manager told us, “I feel connected to the other services.”

The provider had exceptionally 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 always did so with integrity, openness and honesty.

Staff were positive about the leadership of the organisation and the service. They told us they were well supported by leaders who modelled organisational values in their everyday practice. Comments included, “Everyone at Head Office remembers your name, and it’s a big organisation. That’s really personal” and “[Registered manager] is knowledgeable and driven. They make sure we are moving forward, concentration and focus.”
A relative spoke highly about the management of the service. They stated, “[Name] is a good manager, very approachable. I have no complaints.”
The strong leadership and shared direction had a positive impact on people’s outcomes. Staff described how the person had developed their independence and built on their experiences due to consistent care where staff and leaders had high expectations for people. One member of staff told us, “There was a fear of what might happen in social situations. Through guidance and talking to [Name] and giving them the chance, [Name’s] moving forward.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
Staff were confident raising any concerns without fear of negative consequences. They told us there was an emphasis in training about the importance of raising any concerns they might have. Comments included, “Speaking up is drummed into you, very important.” This approach empowered staff to express any concerns and contributed to a sense of psychological safety.

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 valued staff; equality, diversity and inclusion were embedded in everyday practice. Staff told us they were treated fairly and the organisation was aware of any responsibilities they had outside of work or specific health needs. Where needed reasonable adjustments were made to enable staff to work effectively. One member of staff told us, “I can't fault the support they've given me.”
Another member of staff told us how they had been encouraged to progress professionally. They commented, “I’m not that academic but they gave me a chance to step up. I never thought I’d ever have that chance.”
The provider subscribed to a health plan app which employees, and their dependents, could use for support with health care costs. Staff told us they valued this resource. One commented, “I would have had to wait weeks to get a physio appointment without it.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were excellent systems for monitoring and collecting data relating to risks and outcomes. Data was analysed regularly and behaviour analysts, the positive support team, the registered manager and staff at Comprigney Vean were able to respond quickly to any emerging patterns and trends. There was a strong emphasis on using data and experiences to drive improvements and improve outcomes for people.

There were clear roles and responsibilities throughout the organisation. A positive behaviour support (PBS) team included behaviour analysts who were able to accept referrals from services. In addition, the provider had a physical intervention team who worked with services providing bespoke training and monitoring any restrictive practices. The training had been accredited by the British Institute of Learning Disabilities (BILD). Staff told us this training had been relevant to their role and well delivered. Although they had rarely needed to implement it the training had given them confidence. One member of staff told us, “It is refreshed every year and takes 3 days. One day of theory, 2 of practical and then a recap. I don’t think there are many organisations that offer that.” This investment in expertise meant people received care that was focused on their individual needs putting them at the centre of their care.

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 worked with other agencies in order to provide joined up care across services. Information was shared appropriately and in people’s best interest. An external professional commented, “This week my psychiatry colleague and I met with the home manager following a referral for a review of the client's needs.”
Community involvement was promoted with staff taking a pro-active and positive risk-taking approach to supporting the person to regularly engage in meaningful activities in the community. The person was knowledgeable about their local area and had preferred routes through various town centres. The support provided had enabled them to develop their confidence.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

There was a focus on learning from experiences in order to improve outcomes for the person. The registered manager told us; “Staff had become more worried about the risks, there was an element of worry about how things were going to go. Now we'll try it and if [Name] isn't coping well, we'll support [pronoun] through it. We might have to make adaptations, maybe change the time or location.” Daily notes demonstrated this approach was embedded in staff approach.
There was a strong and established culture of sharing information within the staff team to enable consistent care which met the person’s needs. This was done in handovers, debriefs and team meetings. Any restrictions were monitored and reviewed to help ensure they remained proportionate and the least restrictive option.
This approach had resulted in positive outcomes for the person which was supported by analysis of data. The registered manager told us, “Through a consistent support approach, [Name] has been given the time, space, and opportunities needed to communicate how they are feeling. Staff have worked alongside [Name] to better understand and explore the reasons behind emotions and behaviours, while promoting as much choice, independence, and autonomy as possible. As a result, there has been a significant reduction in [Name’s] behaviours of concern.”
When areas for improvement were identified the service was able to request additional support from behavioural analysts employed by the provider. The registered manager had made a referral for support where this was required.
The provider was committed to protecting people’s human rights. Recent changes to legislation relating to DoLS had been discussed at a senior management meeting. A senior manager told us, “We have discussed how we can continue to protect people's human rights in light of the recent DoLS judgement. It is important we as an organisation continue to do that.”