Outreach Office

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 71 (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 promoted a shared vision, strategy and culture founded on dignity, independence, choice, equality, diversity, inclusion and respect for people's rights. This was clearly set out within the service's Statement of Purpose.

The service was led by an effective management team committed to delivering high-quality, person-centred care tailored to individual needs. People using the service and their relatives were encouraged to share their views and were kept informed about developments within the service.

Regular staff meetings were held to provide opportunities for staff to share feedback, discuss their experiences and receive updates on service developments. Meeting records were maintained to ensure information was communicated consistently across the workforce.

Leaders promoted a culture of continuous learning, reflection and improvement. In addition to driving improvements within the service, they contributed to wider sector learning through involvement in research projects exploring workforce recruitment and retention within adult social care and organisational resilience in response to climate change.

The provider demonstrated inclusive leadership, with leaders having the skills, knowledge and experience to lead the service effectively and promote the organisation’s values. Leadership was characterised by openness, integrity and a commitment to supporting staff and people using the service.

Systems were in place to engage staff in the development of the service, including regular team meetings where improvements and service developments were discussed. Staff spoke positively about the leadership team and described leaders as approachable, supportive and responsive. One staff member told us, “The deputy manager goes above and beyond and is always available for support. She always has people’s best interests at heart.”

Some staff commented that the registered manager could increase their visibility within the service. This feedback was discussed during the inspection, and the registered manager was receptive to the comments and demonstrated a willingness to reflect and make improvements.

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

We reviewed complaints and found they were all investigated and closed in a timely manner. Appropriate action had been taken to aid learning and prevent re-occurrence. We found compliments were sent through to the service.

The provider had a range of systems in place to encourage open communication. These included staff surveys, supervisions and staff meetings, which gave staff opportunities to share their views and discuss any concerns.

The provider had a Whistleblowing policy and procedure in place. Whistleblowing is the term used when a member of staff passes on information concerning wrongdoing. There was a culture where staff felt safe and confident to raise concerns without fear of reprisal.

People, relatives and staff told us they would be able to speak up. One person told us, “Yes, I would certainly speak up. I spoke up about someone trying to come into my room and they sorted this.” A staff member told us, “Yes I’m aware, if I witness anything it’s your responsibility to speak up and be protected in doing that.”

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 wellbeing of the workforce was actively promoted. Leaders held regular staff and team meetings, carried out regular staff surveys, and provided structured supervision and appraisal arrangements. These processes gave staff protected opportunities to discuss workload, wellbeing, inclusion and any concerns, and supported reflection on practice and development needs.

Staff had completed Equality, Diversity and Inclusion training, and the provider had robust equality and diversity policies and procedures in place to promote inclusive practice and effectively identify and address discrimination.

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.

Quality assurance systems were in place to monitor safety and quality through a range of audits, including reviews of risk assessments, care records, daily notes, medicines management and staff training. While audits identified areas for improvement, findings were not always consistently incorporated into action plans to ensure all improvements were tracked and completed. A provider visit had also identified that the audit tracker had not been fully maintained.

During the inspection, it was identified that a communal bath was no longer in use, and the reason for this was unclear to the management team. The matter was discussed with the registered manager, who took immediate action to address it.

The management team demonstrated a good understanding of their roles and responsibilities and maintained oversight of the service through a range of monitoring activities, including observational visits to assess staff practice, support performance and promote positive outcomes for people.

Feedback from people, relatives and staff highlighted opportunities to further strengthen the registered manager's visibility within the service. The registered manager was receptive to this feedback and had already begun taking steps to increase their presence and engagement across the service.

Appropriate systems were in place to ensure statutory notifications were submitted to CQC and relevant agencies following significant incidents, accidents and safeguarding concerns.

One staff member told us, “Yes its managed very well, deputy manager registered manager and the owners always checking things, we always do checks.”

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.

A business development plan was in place, which logged, reviewed and acted upon current issues in a timely manner and was used to drive improvement.

Systems and processes were in place to ensure the service worked with partners and the local community, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff and leaders ensured people received holistic and seamless support which met their needs, including engaging with groups and organisations in the local and national community in innovative and proactive ways to support people with their personal identity and interests. For example, the service was involved with the Leeds Care Association and the Headingley Residents Association.

The service worked effectively in partnership with external professionals to support positive experiences and outcomes for people. Leaders also contributed to wider sector learning and development through collaborative working with external organisations and research projects. This included involvement in research exploring barriers to recruiting and retaining male support workers in adult social care and research examining how care providers can strengthen preparedness and resilience in response to climate change.

The provider demonstrated a commitment to continuous learning and improvement through its engagement with research, sector partnerships and workforce wellbeing initiatives. This included work towards Mindful Employer accreditation and the implementation of an Employee Assistance Programme to support staff wellbeing and promote a positive organisational culture. A supported and engaged workforce was recognised as an important factor in delivering positive outcomes for people receiving care.

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 demonstrated a strong commitment to continuous learning and improvement. Feedback from people using the service, relatives and staff was actively encouraged and used to inform service development. One staff member told us, “I think it’s the best company, after needing support around health matters, they’ve been amazing, supported me 100%. It’s the best company I’ve worked for.”

The registered manager reviewed incidents, accidents and audit findings to identify trends and implement actions to reduce risks and improve outcomes. The service also engaged with external networks, including the Leeds Leadership Academy, to remain up to date with best practice, legislative changes and sector developments. Learning from these opportunities was used to drive continuous improvement and support the delivery of high-quality care.

Leaders demonstrated a commitment to learning beyond their own service through involvement in research and sector-wide improvement initiatives. This included contributing to research exploring barriers to recruiting and retaining male support workers within adult social care and participating in research examining how care providers can strengthen preparedness and resilience in response to climate change.