Shalom

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 for this service since its registration under a new provider. 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 demonstrated they had policies and procedures in place to ensure staff understood expectations relating to behaviour and performance.

The values of the organisation were being embedded in the service through supervisions and staff meetings.

The provider of the service had recently changed, and they were working through an improvement plan relating to the environment of the service to ensure it was fit for purpose.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. They 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 registered manager had been in post for several years and was well known to relatives. They felt the registered manager was professional and approachable. Staff also felt the registered manager was approachable helpful and supportive. One member of staff shared how the registered manager had accommodated an extended period of time off when they wanted to return to their home country to visit their family.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt confident that they could safely raise issues with leaders and felt confident that they would be listened to. Staff had regular supervisors and team meetings where issues could be safely raised.

Speaking up procedures were in place for staff who told us they were confident the manager would listen to them if they raised a concern. Staff could tell us what they would do if the manager did not listen to any concerns they raised.

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 manager ensured there was a diverse cultural team who team told us their needs were met appropriately by leaders. For example, this was reflected in giving staff extended holiday time to be able to go to their country of origin to visit their family.

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.

Leaders used a range of monitoring systems to ensure they had oversight of the service. This included paper records such as fire risk assessments and electronic audits for care records. When actions needed to be taken these were recorded and signed off as these actions were completed.

The provider had completed a care home audit which had identified improvement needed. This audit had informed an improvement plan which was being expedited.

Families provided formal and informal feedback to the registered manager.

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. Relatives gave examples of when leaders had worked in partnership with other professionals to ensure people were safely supported. This included health and social care professionals. Professionals also gave positive feedback on partnership working with the service.

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 had systems in place to review and learn from people’s experiences and then to implement appropriate support. Staff were supported to learn and develop within their roles through training, staff meetings and supervisions.