Persona Domiciliary 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.

At our last assessment we rated this key question good. At this assessment the rating has remained 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 68 (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 was guided by their REACH values, Respect, Enthusiasm, Adaptability, Caring and Honesty. The REACH values were used in literature and meetings to firmly embed the values with people, families and staff. One member of staff told us “They (managers) have their values, they live and breathe the values, that is if it’s (regarding) the staff, or (regarding) people they support which is respectful, care, honesty.”Managers told us reviews with people assessed how much “joy” they had in their lives and how to improve on this.

Staff knew and embraced the culture and the values and applied them in their day-to-day work. A staff member, when discussing supporting people with finding a holiday they wanted, said, “This is my focus; I will make sure it happens.” When discussing activities another staff member told us, “I love that these (people) can do these things”. The staff member spoke with knowledge and deep affection to the people supported and referred to them as “our people”

Leaders understood the context in which they delivered care, and support and strived to embody the culture and values of their workforce and organisation.

There was an organisational structure in place and staff understood their roles, responsibilities and contributions to the service and who and when to escalate concerns to 24 hours a day.

Leaders had clear roles, and a new role, Head of Care, was introduced in 2024. Changes to jobs roles had been made in 2024 with the introduction of Operational Support Officers (OSO) who also worked weekends and spent more time in services. All OSO staff received an additional week training by an external company. The provider also had a rising star programme which provided additional fast track training for staff.

There had been a high level of management turnover in one area of the service, managers had left for unconnected reasons. A new manager was now in place, and the provider had taken extra steps to ensure a high level of support to this person. The changes in management had impacted upon the quality of the care within that setting; we found 2 care plans that required improvements and care was not always provided in accordance with care plans and risk assessments; one person was not sufficiently monitored at mealtimes.

The provider fostered an open culture where people felt they could speak up, and their voice would be heard.

Policies and procedure were in place and staff received training, so they knew what was expected of them. A whistleblowing policy was in place and staff felt confident to be able to raise concerns. Most staff said their concerns were listened to but there was a minority of staff who said their concerns around staffing had not been addressed.

People we spoke with felt comfortable approaching staff and told us they could talk to staff if they had any worries. Families knew how to raise concerns.

Senior management strived to prevent closed cultures from occurring. They had an open-door policy for people and families to talk to them at any point. The nominated individual discussed how the manager was very present in the organisation, and we saw people and staff knew who the manager and were keen to talk to her and share their stories. At all the properties we visited we saw people called into the offices to have casual conversations with managers and staff.

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 understood the importance of having a fair and inclusive workplace. Staff were recruited fairly and had training, policies and procedures that supported their knowledge of equality, diversity and inclusion. These themes were evident in the conversations we had with staff members.

Persona Domiciliary Support Service had an employment pathways service; this supported people and employers to overcome barriers to employment for supported people. A person supported by Persona had gained paid employment as a recruitment interviewer and had already been instrumental in the recruitment of new staff.

Persona had achieved full member status of the Greater Manchester Good Employment Charter, who aim to raise employment standards across Greater Manchester.

Most staff spoke positively about the provider supporting them. Staff told us managers were “Supportive of staff and work life balance” and that “towards us (staff) they’re very flexible if I have an emergency or need leave or swap a shift, they’re very accommodating. They do really try to help.”

The provider had introduced a new rota management system. The system sets parameters on maximum hours worked, shift length, days off, and matched skills required to support a person. This promoted a flexible and person-centred workforce. Staff could choose to work over the set maximum hours, and the system allowed managers to focus on staff wellbeing where this happened.

Staff had opportunities to feedback through additional channels such as their annual workshop, AGM and staff survey’s.

The provider did not always have clear systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

The provider’s auditing systems were not always robust. They completed a range of checks and audits to monitor the quality and safety of the service, and these were subject to ongoing reviews and improvements. The provider was in the process of reviewing their auditing systems. New systems were being implemented, to help provide improved oversight. The new electronic care system could highlight missing information, missed recordings and themes and trends. However, we found issues with care plans, risk assessments, monitoring systems and safety that had not been identified in the audits.

When highlighted, the provider was responsive and took immediate action and new or improved auditing processes were implemented and distributed throughout the organisation to help drive improvements.

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.

Managers and staff work in partnership with other health and social care organisations to achieve better outcomes for people. We saw evidence of attendance at multi-disciplinary meetings, care reviews, and best interest meetings that ensured the person reached holistic level of care and there was a proportionate response to risk. This level of joint working ensured people were able to have increased independence and more control and enjoyment in the lives. We saw evidence of the provider requesting reassessment when decisions on commissioned hours for people did not meet needs.

The provider worked well with commissioners and other professionals.

The provider had strong community connections, and this resulted in numerous initiatives that had benefitted people and their communities. This included volunteering, gaining employment for the first time, steps to travelling outside of the home for the first time, establishing new groups for shared interests, social groups, community use such as parties in the park, the green café, and the ‘Going Green’ initiative. People and staff were involved in fundraising events; this had enabled them to raise money for a local hospice. These activities benefitted the community as well as increasing people’s community connections, confidence, independence and pride.

The provider was involved in the establishment of new housing provision in the locality that was near completion. The provider had worked with the housing association and social care professionals to promote integration and support networks for people to live as independently as possible in the community.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. Processes were in place to ensure learning happened when things went wrong and staff told us how this information was shared with them. Policy had been updated following a complaint which safeguarded peoples finances.

Electronic systems were being introduced during this assessment and consideration for further electronic recording systems such as medication files was in place. A new online training package for staff was also introduced during our assessment.

Most staff felt encouraged to raise issues to help improve people’s lives where required. Staff were encouraged to share views in meetings. Forums for people and staff were in place, attendance at these meetings was encouraged. Minutes were shared and in accessible formats.

One staff member described how they had monitored medication rounds by observation and staff feedback and then made alterations to the procedures to reduce the potential for errors due to distractions and interruptions that were taking place.

Were we saw shortfalls, the provider took immediate actions, spoke to staff and updated processes which showed a commitment to improving the service for people.