SUPPORTED LIVING ENABLEMENT SERVICES

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 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. 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 71 (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 engagement understanding challenges and the needs of people.

The registered manager had a clear vision for the service and the values they wanted it to promote. They told us they wanted to provide care that was compassionate, person-centred and focused on treating people as they would members of their own family. The registered manager and senior staff regularly worked alongside care staff to provide support and cover absences. This helped them build positive relationships with people, maintain an up-to-date understanding of their needs and provide effective support to staff.

Staff understood their roles and responsibilities. They described leaders as approachable, supportive and responsive and said they set clear expectations about standards of care and professional conduct. This helped promote a positive culture and effective teamwork.

The registered manager had a planned and sustainable approach to service development. They demonstrated a good understanding of the service's capacity and the factors that would need to be considered before expanding further. This helped ensure growth could be managed safely.

The provider had inclusive leaders at all levels who had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager took an active role in the day-to-day management of the service. This included overseeing operational responsibilities and regularly delivering care. As the service was small, this dual role was manageable and sustainable at the time of the inspection. The registered manager told us they intended to reduce their involvement in direct care as the service grew, allowing them to focus more on their management and oversight responsibilities.

The registered manager had the skills, qualifications and experience needed for their role. They had a background in nursing and health and social care, which supported their understanding of the role and its responsibilities. They were also receptive to feedback from professionals and demonstrated a willingness to reflect on and improve practice.

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

Staff told us they were confident raising concerns and described leaders as receptive to feedback. The provider's whistleblowing procedures outlined how staff could escalate concerns both within and outside the organisation. This encouraged openness and helped ensure potential risks to people and the quality of care were identified and addressed.

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 had policies and procedures to promote equality, diversity and inclusion within the workforce. Staff told us they felt valued, treated fairly and supported in their roles.

The registered manager considered staff wellbeing when organising work schedules and provided opportunities for staff to share feedback about their experiences of working for the service. This helped create a positive and supportive working environment.

The provider did not always have clear systems of accountability and governance. Although leaders were developing more effective oversight arrangements, these processes had not yet been fully embedded.

We identified a notifiable incident that had not been reported to CQC as required. Following the inspection, the registered manager submitted the notification and reviewed previous incidents to ensure no other notifications had been missed.

The registered manager recognised the need to further develop and evidence staff engagement activities. Staff told us they received regular support and supervision; however, these discussions were often informal and not always recorded. Similarly, records of spot checks and competency assessments were not consistently maintained. As a result, it was not always possible to demonstrate how staff performance, development and wellbeing were monitored.

The provider had systems in place to monitor care delivery. However, the registered manager told us they were not making full use of their electronic care management system to monitor areas such as call compliance and medicines administration because of limitations in its functionality. As the service was small, they maintained oversight through regular contact with staff and people using the service. However, they recognised more formal monitoring arrangements would be required as the service grew and were actively exploring alternative electronic systems.

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 registered manager described how working with external professionals had helped improve people's outcomes. For example, they worked with professionals to support people to reduce or stop smoking, manage eating and drinking needs, and respond to changes in mobility.

The provider focused on continuous learning, innovation and improvement across the organisation.

The registered manager actively sought opportunities to improve the quality of care and develop governance systems. For example, the provider had a service improvement plan in place which identified areas for development through audits, reviews and stakeholder feedback.

The plan set out clear actions, identified those responsible for implementing improvements and described how progress would be monitored. It included several areas also identified during our inspection, including the need to improve systems for recording, reporting and overseeing incidents.

The provider had completed many of the actions identified within the plan, while others remained in progress. Although changes were still being embedded, they demonstrated a commitment to improving the quality and safety of the service.