Care Quality Services Potter’s Court

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. 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 service understood the challenges and needs of people being supported. The care people received reflected the service’s values and objectives as set out in their statement of purpose. The provider had a clear vision of how to grow the service through the use of technology without compromising safety and quality. The provider promoted a positive, open culture and inclusive ethos.
The provider used team meetings to ensure staff were aware of their values and what was important. Staff told us they were happy with the company and its values.
Staff told us there was a culture of collaboration, where people and staff were listened to and communicated with. This demonstrated a pro-active approach to engagement with staff to improve the culture at the service.
 

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.

Staff told us leaders were open and honest, and they were able to contact them when needed. Senior staff had received appropriate training and ongoing development programmes relevant to their roles. The registered manager and field care manager were both working towards their level 5 in Health and Social Care leadership. The registered manager knew what needed to be referred to safeguarding and what notifications needed to be made to CQC.
 

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

Staff told us they felt comfortable speaking up and raising issues to senior staff. The provider had a whistleblowing policy in place and staff had received training in line with this policy. The provider demonstrated an open approach in their engagement with staff and acted to address their concerns when known. Staff knew who and what to report both inside and outside of the service and felt encouraged to do so by the provider. One staff member told us, “I haven't spoken up but they do encourage it.”
 

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. There was additional support for staff new to care or during induction and shadowing. Staff from an ethnic minority background told us they felt part of the team and well supported by the provider.
There were policies in place for equality which staff had access to. The provider had employed a diverse workforce.
Staff training was up to date for staff on the training matrix covering equality and diversity.
 

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 service had regular checks and audits in place. This included call monitoring, recruitment and care reviews. Monthly eMAR audits, 6-month audit of staff files and people’s files. There was also a compliance dashboard for supervisions, which helped senior staff monitor when staff supervisions were due.
There was a suitable business continuity plan in place, which included prioritising care for the most vulnerable of people supported. People had their priority rating on the provider’s online care system RAG (Red Amber Green) rated. This helped to clearly document people’s care requirements.
The provider obtained feedback from people via their “Voice of the customer” surveys as well as compliments and complaints to have better oversight of people’s experience.
 

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.

There was evidence of partnership working with key stakeholders, including commissioners, other providers and health professionals. For example, the provider worked closely with social workers for reviews of care, district nurses and occupational therapists for the best outcome for the people they support. Staff told us if they raised any concerns the office staff would follow up with professionals in a timely manner to get the support needed for people. Senior staff also told us they followed up with GPs to share updates. This helped to promote positive outcomes for people using the service. The local authority quality and safeguarding team confirmed there had been an improvement with the service over the last year. Their assessment outcome of the service changed from requires improvement to good from 2024 to 2025.
 

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. They actively contributed to safe, effective practice and research.
The provider had a service improvement plan in place based on feedback from people, auditing and external professionals. The provider had also started using a “You said, we did” process to show people what they had done from their feedback.
The provider had falls risk process linked to their care system which used information available to determine a person’s falls risk. Depending on the level of risk, it would automatically add extra care tasks for staff to help mitigate this risk. The provider told us this had reduced the number of falls by 20% across their services.
The provider had also started using artificial intelligence (AI) to help write their care plans. We acknowledged the care plans we reviewed were of a good quality.