Hazel Villa

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

We looked at all quality statements for Well-led at this assessment. The service was Well-led. The provider had safe and effective governance systems.

There was an inclusive and positive culture of continuous learning and improvement. This was based on meeting the needs of people who use services and wider communities, and all leaders and staff share this.

Leaders proactively support staff and collaborate with people who use services and partners to deliver care that is safe, integrated and person-centred. Leaders drove efforts to increase sustainability, and design services to reduce inequalities for staff and people who use services.

There were effective governance and management systems. Information and data are used appropriately to check risk, performance and quality of 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 an overall vision for the continuing improvement, direction and development of the service for the long term that ensured management and staff knew what was expected of them. The provider had actively involved them for the purpose of improving the culture and quality of the service. One staff member told us, “We have regular team leader meetings, where we discuss ideas to motivate people, and ideas on how to shape change for people. Ethos of service is ‘openness and transparency’, everyone communicates, the provider, registered manager, team leaders and support staff. We all share ideas and have a meeting of minds in the middle to ensure best quality of life for people.”

Interview processes provided good exploration of what a potential new staff member could bring to the role, their values, how they communicated with people, different methods of communication, their understanding of mental health needs and equality and diversity. The service was focused on continued learning and improvement. There was an ongoing development plan to plan for and drive improvement. The provider was currently working on a shared vision, values and strategy in collaboration with staff and people who use the service.

The service had inclusive leaders at all levels who understood the context in which they delivered care and support and embodied the culture and values of their workforce and organisation. Leaders at every level were visible and led by example, modelling inclusive behaviours. The provider told us they had the tree of life as the organisations logo, they said this was because, “Everyone has a home here.” The provider had won the ‘Putting People First Award’ at the 2024 Great British Care Awards for his dedication and commitment to people using the service, showing how they tailored their service to meet the unique needs of each person, empowering them to take greater control over the care and support they received.

From our discussions with the provider and registered manager it was clear they had the knowledge and credibility to lead effectively. Leaders were alert to examples of poor culture that affected the quality of people’s care and promptly addressed them.

There was a structured support system provided to the new registered manager for succession and development in their role. There were systems in place to ensure staff were provided with regular support and guidance to enable them to effectively carry out their role.

Staff and leaders acted with openness, honesty and transparency. Staff told us there was a culture of speaking up where staff can actively raise concerns, and they were supported without fear of detriment. A staff member told us, “All staff know if they speak up about something it stays confidential. They know they can trust managers here, and that if they have a concern, it will be dealt with.”

There was evidence to show when concerns were raised, leaders investigated sensitively and confidentially, lessons were shared and acted on.

The provider told us, “Equality, diversity and inclusion are the root of our mission statement. Cultural differences bring something to the table from the directors down.” A member of the quality team had won ‘The Three R’s Award’ at the 2024 Great British Care Awards. This award 'highlighted initiatives that foster a positive work environment, encourage professional growth, and shows a commitment to recognising and rewarding staff contributions'. A staff member told us, “I am really impressed by D&S Healthcare as a company, I think they will go far. Next year at the care awards, we are going to be the best. We all share that aspiration, we are committed to making the improvements needed, we are a team, everyone does their best.”

The provider had systems in place to continually review and improve the culture of the service.

There was effective leadership to oversee and direct staff on each shift, and roles and responsibilities were clearly defined.

The provider had robust and effective governance systems to proactively and continually assess the quality and safety of the service, drive improvement or find where lapses had occurred. There were robust arrangements for the availability, integrity and confidentiality of data, records, and data management systems. Information was used effectively to check and improve the quality of care. The provider had a pro-active approach to learning and development to prioritise staff training and develop a confident and competent workforce, ultimately improving the lives of people using the service.

The service was open and transparent and worked well with key organisations to support care provision and joined up care.

Staff and leaders worked in partnership with a wide range of healthcare professionals and key organisations to provide continued and joined-up care for people.

We received positive feedback from partners, that the service was open, transparent and responsive. One professional told us, “It has been a pleasure working with D&S Healthcare, at provider level there has been regular communication and contact with ourselves as a Local Authority, through the transition period and beyond this point” and “There has been professional transparency from both provider and management levels.”

The provider formed good working relationship with CQC through transition to support service provision. They provided weekly reports telling us about the improvements they were making and how the service was developing. The service also worked well with other organisations as relevant to support people’s care and support needs.

Staff and leaders had a good understanding of how to make improvement happen. The approach was consistent and included measuring outcomes and impact. Staff and leaders ensured that people using the service, their families and carers were involved in developing and evaluating improvement and innovation initiatives. They encouraged creative ways of delivering equality of access, experience, outcome, and quality of life for people.

The provider and management had robust systems to ensure that learning happened when things went wrong. There was a record of actions and lessons learned taken forward from recent events. Staff were supported to develop skills around improvement.