Catherine Tam Agency

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

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.

At our last assessment we rated this key question outstanding. At this assessment the rating has remained outstanding.

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 89 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The provider had an exceptional culture of care whereby staff felt truly valued and respected. This spanned across people in all roles, be this support staff or maintenance staff.

Staff demonstrated an understanding of the service’s values and recognised their responsibility to ensure people felt cared for, respected, and valued. Staff were motivated and proud to work for the service.

Staff described they felt confident to share feedback or raise concerns, and knew their voices would be welcomed and acted upon. They told us management were consistently approachable, visible within the service, and genuinely invested in their wellbeing. They confirmed the management team took time to check in, offered support, and ensured the team felt encouraged and appreciated.

The provider also demonstrated a strong commitment to partnership working. They collaborated proactively with healthcare teams, social workers, and local authorities, creating a network of support around each person. Every professional who shared feedback only had praise and positive experiences to share.

Relatives told us the provider was open, transparent, and approachable and this enabled them to feel comfortable to speak with them regarding any issues or concerns. They felt confident that any concerns raised would be listened to and addressed promptly. This contributed to a positive relationship between families and the service.

The provider had exceptionally 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 always did so with integrity, openness and honesty.

Managers and staff showed passion for the service and for what they aspired to achieve. They were passionate about enabling the people who used the service and their staff wellbeing. They acted as role models for the whole staff team, worked alongside them to support people on a daily basis. Staff told us management were always available when needed. People who used the service told is they could call the management team at any point if they had any questions. We saw an open-door and transparent approach with the management, where people who used the service, and staff, could visit for a drink and a chat at any time, break down barriers and fostered trusting relationships and a sense of belonging.

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

Staff told us there was an open culture and they were encouraged to share their thoughts and experiences.

There were effective systems in place to enable staff and people to speak up.

People who used the service and those important to them had opportunities to share their views on the quality of the service. We saw a relative request a GP review for reassurance on their loved one’s healthcare. The provider listened and arranged for the review.

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them.

The service showed a clear and sustained commitment that promoted independence, equality, and inclusion. For example, the provider had provided meaningful volunteering opportunities. The service recognised each person’s abilities and provided long‑term guidance to achieve positive outcomes for people.

Equality, diversity and inclusion were consistently and actively promoted by staff and the provider taking proactive steps to support people from a range of cultural backgrounds.

The provider demonstrated a strong commitment to deliver effective, high‑quality training that improved knowledge, skills, and outcomes.

Staff shared examples where the provider supported a healthy work-life balance and where they had been supported to manage their own health and well-being. As mentioned previously, staff told us they had been provided with free counselling where needed. This support helped staff feel valued and ensured they remained confident and integral members of the team.

The provider supported staff to maintain their work visas if needed, and where suitable, supported them with career progression. Staff were supported not only within the service, but externally to receive qualifications, this included their nurse associate training.

The service provided placement opportunities for several college and university students across their services. This offered people from different health and social care professions the opportunity to learn new skills and work in a well-established care environment.

The strong commitment to equality, diversity and inclusion contributed directly to the positive, uplifting culture within the service.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Governance was strongly embedded and there was a robust framework of accountability, positive risk management and continuous improvement.

The staff team used technology effectively. The provider had a confidential private instant message system that was used by staff to share information, this included people's achievements.

Audits were completed regularly to monitor the service. This enabled any trends to be identified to ensure the service met the requirements and needs of people who used the service.

There was regular oversight of the service through spot checks, regular supervisions, audits, and ongoing communication with people who used the service and their relatives. People and families consistently said management checked in with them regularly.

The registered manager recognised their responsibilities under the duty of candour requirements and followed the service’s policies and procedures. Where required, the provider had shared information with relevant external stakeholders.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

Staff consistently went above and beyond to enable community presence and inclusion. They supported people to build and maintain meaningful relationships with others; this helped them feel valued.

Partnership working was a clear strength of the service. We observed highly effective collaboration with a range of external stakeholders, which included social workers, healthcare professionals and charities. One external organisation told us, “Staff at Catherine Tam have regular meetings with our organisation and with the service user's family to provide reassurance to the family, ensure relationships can be collaborative and, importantly, to continually adapt provision to meet the unique needs of the service user and to sustain family bonds in difficult circumstances. Senior staff lead from the front on this. The level of communication and collaboration with us as an external agency is second to none.”

The provider demonstrated an exceptional commitment to partnership working and community engagement. This placed people at the centre of all collaboration. They worked proactively and creatively with stakeholders, relatives and other organisations to ensure people’s individual goals and outcomes were achieved. This was particularly evident where a person, whose cultural background would not usually accept care from outside their family, was supported to engage with services through sensitive and respectful relationship-building. By working with external organisations, the provider was able to adopt a culturally informed approach, which promoted independence and built trust and close links with loved ones. As a result, the person was safeguarded from harm, experienced improved wellbeing and successfully rebuilt important family relationships. This outstanding level of collaboration ensured outcomes that would not have been possible without such strong, inclusive and responsive partnership working.

A multi-disciplinary approach enabled the development of consistently person-centred care plans that reflected both clinical expertise and the individual’s preferences, needs and goals.

Overall, the provider’s approach to teamwork and partnership working was exceptional. There was clear evidence of strong leadership, effective communication and a shared commitment across all teams and services to deliver high-quality, person-centred care.

The provider had a strong, embedded culture of continuous learning, improvement and innovation. Leaders and staff actively sought and applied new ways of working to improve outcomes, experiences and quality of life for people, with a clear focus on equity and person-centred care.

There were effective systems to assess, monitor and improve the quality and safety of the service. Regular health and safety audits were completed, and findings were used to inform timely action plans, which were monitored to ensure sustainable improvements and shared learning.

The provider worked collaboratively to improve care, which contributed to research and innovation internally, but also within the wider community. This included participation in research projects with local universities, that demonstrated a proactive approach to developing safe, effective practice and drive improvements beyond the service. This learning from the research was embedded within the service, included supporting people with end-of-life care. By doing so, people they supported had better outcomes and meaningful support.

The provider consistently demonstrated a proactive, learning-focused approach that supported high-quality, safe and continually improving care.