Shrewsbury Road - Max Potential

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 provider had a clear Statement of Purpose and vision and strategy for the service which the leaders were aware of. The atmosphere in the home was positive and reflected a supportive staff culture. A range of different staff team meetings were held regularly to provide updates, to identify from staff’s perspective any potential gaps in quality. This ensured as a service, the provider was meeting people’s needs, and leaders engaged regularly with the staff team.

The registered manager told us compatibility was important when any considering any new potential referrals; this was verified by a relative who told us, “I was reassured when the registered manager said to me that he won't be introducing a new person resident if they don't get on with the other existing residents.”

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 provider ensured there was always suitable managerial cover; this included leaders being available to provide advice to staff call throughout the night. A staff member told us, “It’s a good place to work and there is an open culture. All of the staff team work well together and handovers are done.”

Leaders of the service were suitably experienced and qualified and had clearly defined roles and accountabilities. Several leaders had worked previously in the social care sector and so had the skills and competence to get involved in the direct delivery of care if required.

Leaders were knowledgeable about issues and priorities for the service and had access to appropriate support. Leaders took full responsibility within their roles and challenged poor performance when necessary.

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

Staff and leaders actively promoted staff empowerment to drive improvement; they encouraged staff to raise concerns and promoted the value of doing so. There were mechanisms in place for staff to speak up and a culture in place to encourage them to do so. The employee handbook held details about whistleblowing. The provider had an up-to-date freedom to speak up / whistleblowing policy was in place.

Staff told us the felt able to raise concerns and that they would be listened to. We saw comments made in most recent staff survey completed in summer 2025, were overwhelmingly positive; communication and care planning achieved a 100% positive staff response, there was a slight reduction in overall role satisfaction, which suggested workload or role pressures, may have impacted a small number of staff. Staff confidence in training had improved.

Good communication was in place through the on-call system, team meetings and formal 1-1 sessions to ensure staff had regular opportunities to engage with leaders. This was also supported by policies and information supporting staff to raise concerns externally if required.

People and relatives felt their voice was heard. One relative said, “Making the move to Shrewsbury Road was a good decision because [person] was becoming isolated at home, but 'letting go' had been hard. The registered manager understood this and we agreed that they staff would call me if they needed any information about [person].” The relative told us the registered manager had organised a smooth transition for them and said, “They've been amazing.”

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.

Leaders provided flexible working agreements to staff to account for personal circumstances such as caring responsibilities and health issues and had put reasonable adjustments in place for some staff to help them carry out their role; this was confirmed by staff we spoke with.

Leaders took steps to ensure staff were representative of the population of people being supported. Staff told us they were treated equally by leaders. One staff member told us, “Managers are very good and it was part of the reason why I came here, as they are open and approachable, your opinions count and I feel supported.”

Managers engaged with staff via appropriate forums such as supervision and staff surveys, to ensure their voices were heard. Most staff were confident they could raise concerns directly with their leaders, and had received training in equality, diversity and human rights.

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.

Staff were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. A clear organisational staff infrastructure was in place.

The provider operated effective governance processes; audit systems ensured staff were undertaking regular clinical audits, and analysis of recorded accident and incident data was in place to provide trend analysis and lessons learned. We found clear systems of recording and handover, which supported staff at all levels to work safely with people. Managers and staff were clear on the risks they faced and worked hard to make improvements and mitigate any risks. Performance and risks were routinely discussed in staff and leaders meetings.

A range of operational meetings, were used to review data, including any incidents, complaints, weight loss, medication errors, and any further concerns. There were regular meetings, focusing on clinical risk and oversight of people’s assessed needs to ensure appropriate action had been taken.

The provider had a business continuity plan, which covered the relevant areas. Policies which were reviewed as part of this inspection were up to date.

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.

Staff and leaders were open and transparent and collaborated with all relevant external stakeholders and agencies. The provider engaged in various meetings with external stakeholders including the local authority.

The provider updated and sought guidance and involvement from relevant healthcare professionals. The provider documented feedback, including meetings and meaningful engagements with staff, people and the wider community. Daily records identified any activities people had been involved in. A person told us, "We go shopping and go to the supermarket, and I go cycling and do basketball. My friend also visits every week."

During our site visit we noted very good staff interactions throughout and it was clear people got on well with the staff supporting them. People’s daily lifestyle was identified in their care plans; this provided information on what each person was interested in and liked to take part in. The provider operated a day centre in the local area, which was free for people to access, and people had the opportunity to go on an annual holiday.

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 suitable systems and policies to ensure continuous learning and improvement. We noted where concerns had been identified, these concerns were shared with the staff team. The registered manager was responsive to feedback from all sources. A staff member told us, “We are encouraged to report any bad practice and be open.”

The provider was committed in ensuring quality assurance was in place to maintain high standards of care and ensure the well-being of people being supported. There were clear and established standards for various aspects of care such as medication management and people’s safety. The provider and registered manager regularly reviewed incidents and any necessary improvement actions were recorded.

The provider regularly assessed the care provided through audits, internal quality assurance visits, and by analysing feedback from people and their relatives. Data including incident reporting and health outcomes was collected and analysed to identify areas for improvement. Governance meetings were held regularly to identify any areas of concern.

The provider adequately trained staff and they understood the quality standards and procedures. A relative told us, “The staff have got to know [person]. If [person] is not coping, they [staff] understand how to speak to [them] and they do understand [person’s] needs."

All staff we spoke with confirmed leaders encouraged them to speak up with ideas for improvement and innovation and actively invested time to listen and engage; we also verified this by looking at a range of meetings which had taken place throughout the year.