Diana’s Quality Care Ltd

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• 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 newly registered 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.

People said staff maintained professional boundaries and respected their dignity, privacy, preferences and individual needs. Staff sought people’s consent, involved them in decisions and supported them in a respectful and person-centred way.

Records showed policies and procedures supported effective communication. Staff understood the guidance and described how they adapted their approach to people’s individual communication needs, checked understanding and shared information appropriately while maintaining confidentiality.

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.

The registered manager demonstrated a good understanding of their responsibilities for safeguarding, governance, quality assurance and person-centred care. This included promoting people’s safety and rights, monitoring the quality of the service, identifying areas for improvement and ensuring care reflected people’s individual needs and preferences.

Staff told us the registered manager was contactable and provided advice and support when needed, including during evenings and weekends. One staff member said, “I can call the registered manager anytime.”

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

The registered manager encouraged feedback from people, relatives and staff, and viewed concerns as opportunities for learning and service improvement. Feedback was used to identify themes, inform action and support ongoing improvements to the quality and safety of care.

Staff understood the organisation’s whistleblowing policy and knew how to raise concerns. Staff told us they felt confident concerns would be taken seriously, and action would be taken to keep people safe. One staff member said, “I know how to whistle blow if I need to. I’m very confident the manager would take appropriate action to ensure people are safe.”

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 promoted equality, diversity and inclusion among staff through its policies and employment practices. These set expectations for fair treatment, inclusive recruitment, equal access to training and development, and reasonable adjustments where required. Staff were encouraged to raise concerns, and managers were expected to address any discriminatory practice and foster a respectful workplace culture.

Staff told us they felt valued, supported and respected by the manager. One staff said, “I feel respected by my manager”

The provider had clear roles, responsibilities and governance arrangements. For example, managers reviewed incidents, complaints, staffing and care outcomes at regular governance meetings. They used identified risks and trends to agree actions, allocate responsibility and monitor completion. Information was shared securely with relevant professionals where required.

The provider had systems to monitor quality and safety, manage risks and review performance. Audits of medicines, care records and incidents supported leaders to identify concerns, assign actions and monitor progress. Findings were reviewed to identify themes, share learning and strengthen practice. Leaders maintained oversight of action plans and checked that improvements were completed and sustained.

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 provider worked with external professionals and agencies to coordinate people’s care and support. This helped people access the services they needed and supported continuity of care.

Feedback from a professional told as,“The [Manager] goes above and beyond for the adults she supports and provides a personal approach. She is highly regarded by the adult and their family, responds promptly, is easy to contact, and provides care records when requested.”

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.

Leaders encouraged staff to reflect on practice, share learning and explore new ways of improving people’s experiences, outcomes and quality of life. They supported safe and effective practice by engaging with relevant partners, guidance and research, and using learning to inform service development.

Quality assurance systems were used to monitor performance, identify risks and areas for development, and support positive outcomes for people. Audit findings, feedback, incidents and other performance information informed improvement plans. Leaders monitored progress, shared learning with staff and checked that changes were embedded and sustained.