SeeAbility South Gloucestershire Support Service

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 type of supported living. This key question has been rated requires improvement.This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.The service was in breach of legal regulation in relation to governance at the service and failure to notify us of events that are reportable to the Care Quality Commission.

This service scored 62 (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. However, due to management changes this was not fully embedded in the service.

Since 2015 there had been 7 registered managers, and the manager told us there had been 4 managers since 2021. A person told us there had been 14 managers since the service opened and lots of good staff had left. The manager told us 8 staff had left in the last 12 months. Exit interviews were conducted to establish the reasons for staff leaving and to assist in making improvements. This meant there had been a lack of stability for people and staff in respect of the management of the service.

The newly appointed manager had made improvements to the service addressing areas such as communication with staff. This included ensuring regular team meetings and organising training to support staff in their roles.

The provider completed a retention, engagement and culture review of the service in March 2025. All staff were interviewed and their views sought on how the service was performing. This highlighted some areas for improvement including improving communication, sharing wider information about SeeAbility, ensuring training was provided to staff in a timely way and to ensure regular team meetings were taking place. It was evident the new manager was completing the action plan to drive improvements in the service and ensuring staff were aware of the vision of the service. The improvements in these areas commenced in May 2025 when the new manager commenced in post and they were still working through the action plan to address some of the shortfalls.

Staff were clear on their roles in supporting people to live the life they wanted. Staff reported that morale was much better since the new manager commenced in post. They confirmed there was now an open-door policy, but this had not always been the case. A member of staff said, “Our new manager has been fantastic. She demonstrates great professionalism and has brought a wave of positive energy to the service”.

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.

There was a strong senior management presence throughout the assessment. The regional manager supported the manager throughout the process assisting with providing evidence and supporting on 2 of our visits to the service. They visited the service on a regular basis and met with the manager and other managers they were responsible for on a weekly basis via video call and monthly face to face.

The manager said they had been supported during their induction period, meeting with all departments within the organisation and this helped with getting to know the values and expectations of the service. The quality lead and safeguarding lead regularly visited the service to ensure ongoing compliance and improvement, alongside supporting the new manager.

A member of staff told us how their induction had not been as positive as it should have been under a previous manager. They said once this had been identified, a member of the people team visited them and provided additional support and direction. This included meeting with heads of departments to increase their knowledge, enabling them to build on their skills and knowledge. They told us under the direction of a new manager, they now have weekly meetings to discuss any concerns within the area that they were responsible for, with weekly visits which included checking on compliance and providing support.

The senior management team were open and honest about the areas for improvement and working with the team to make changes to the culture of the service. This was echoed in the action plan that had been devised for the service from the recent audit on retention and the culture of the service and monthly compliance visits. People, relatives and staff confirmed that there was a good leadership presence within the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.Whilst it was evident that staff had not always felt they could speak up, from talking with staff and people this had changed significantly. People and staff confirmed the manager had an open-door policy and a presence within the service.

The provider had policies in place to provide guidance on whistleblowing, speaking up and managing complaints. Staff could raise concerns anonymously via an independent support line.

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 was committed to promoting equality and inclusion across the workforce. Staff told us their personal circumstances were respected. For example, one staff member told us that adjustments had been made to enable them to continue to work. The team was multi-cultural, and policies and procedures were in place to support the diversity of the workforce to ensure they were free from discrimination.

No one raised concerns with us about equality in the workplace.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s quality monitoring system was not robust to ensure regulatory requirements were met. We identified shortfalls in relation to medicine management, the monitoring of risk within the service for individuals, supporting people with goal planning and staff training. The provider's quality assurance processes had not identified all these areas of concern and where they had, timely action was not taken to address these shortfalls. For example, an audit completed in March 2025 had identified that people’s goals needed to improve and this had been signed off on the quality tool as being met in June 2025. However, we found shortfalls in this area, as described in the responsive section of this report. The provider’s audits had not identified the areas of concern relating to people’s risk assessments and keeping people safe.

A robust system was not in place to ensure events at the service were notified to CQC in line with legal requirements. We had not been notified of the outcome of the Court of Protection Deprivation of Liberty Safeguards for people using the service and an allegation of abuse.

The manager had submitted their application to register with the Care Quality Commission.

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.

Health and social care professionals were positive about the way the service worked in collaboration with them and supported people.

The manager was part of a number of networks, and they told us they were very useful in keeping themselves and staff up to date. This included a local provider network and a forum for registered managers.

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 manager and deputy manager were open and responsive to our findings during the assessment and acted on areas of improvements we identified. For example, ensuring medicines were safe and secure. They were passionate about providing person centred care to people and had plans to improve people’s experiences.

When audits such as manager or quality assurance team audits were completed, any identified actions were uploaded to the service’s action plan. This was monitored by the quality team and the regional manager. It was evident that the new manager was making progress with the action plan and making improvements to the culture of the service, developing the team and improving outcomes for people.