Office 510 Kingsfield Close, NN5 7QS

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 questiongood. At thisassessmentthe rating haschanged torequires improvement.

Requires improvement:This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 62 (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. Staff told us the culture of the service was “very positive and supportive.” The staff and management team spoke of the importance of compassion in the work they do with people. The Registered Manager told us they promote equality and diversity within the staff team by encouraging diverse candidates to apply for roles and valuing their unique perspectives.

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. Staff told us the management team were “very knowledgeable.” There was a Registered Manager in post, and they were supported by a clinical lead with a nursing background.The management team lead by example and often acted as second carer to support staff where 2 people were required for a care call. This provided opportunities to observe care and gather feedback from people about their support.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt able to speak up and share any concerns or feedback with the management team. One staff member said “Yes, the staff team are openand honest with the manager. There is a culture of trust and good communication, where staff feel comfortable sharing ideas or concerns.” We saw that staff had opportunities to share feedback in team meetings and individual supervision sessions.

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. Whilst there were no staff who required reasonable adjustments because of disability, the Registered Manager understood their responsibilities under the Equality Act. Staff told us they were treated with respect and support.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The service had changed its service provision in 2024. Where they used to provide supported living to autistic people and those with a learning disability, they were now providing domiciliary care predominately to older people. The service had not updated the service user bands they covered to reflect this change. This was raised with the Registered Manager during the assessment, and they agreed to apply for the additional service user bands immediately. There was no system of oversight of care documentation and the management team relied on staff feeding back people’s preferences for care and any issues that arose. This meant that opportunities for collaboration with people were lost and care plans lacked some key information. Whilst the quality of the care provided was good, this was due to experienced care staff building a rapport with people, rather than the care planning and guidance from the management team. The Registered Manager had not identified the issues seen during the assessment and care plans were not audited to ensure their accuracy and completeness.

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 service worked closely with staff from the hospital and Local Authority which enabled the smooth transition from hospital to long term care. The management team supported social worker’s reassessment of people’s needs at the end of the short-term care package. They were also available for incoming care agencies to discuss aspects of people’s care and support.

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 Registered Manager told us they linked into the Local Authority’s provider networks and took up offers of training and development that were shared. Team meetings and supervision were used as opportunities for continued learning. Staff were supported to keep their training up to date. The management team were open to feedback and acted on this where needed.