ASLN

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 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 spoke positively about the open and inclusive culture within the organisation. They told us this culture promoted person‑centred care and encouraged people to develop independence and make choices about their lives. One staff member said, “These values are to be honest and transparent in all interactions, treating the service user with kindness and empathy and striving to give them the highest possible standards in every task that we do. To be accessible and welcoming to everybody.”

The management team demonstrated a commitment to learning and continuous improvement. They welcomed feedback from the inspection process and viewed it as an opportunity to reflect and improve the quality of the service. This approach helped to foster a shared understanding of values, priorities, and expectations across the staff team.

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 management team demonstrated capable, compassionate and inclusive leadership. They were responsive to feedback shared during the inspection and showed a clear commitment to continuous improvement. Leaders were knowledgeable about current guidance and best practice and explained how they kept themselves and staff up to date with changes to ensure safe and effective care delivery.

Staff spoke positively about the management of the service and felt well supported. One staff member told us, “The management of the service is responsive, supportive, approachable and well organised, providing clear leadership and guidance in line with standards set by the Care Quality Commission to ensure safe and effective care delivery.”

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

Staff understood how to raise concerns and were confident in doing so. They told us there was a positive and open culture within the service where they could speak up if needed. Staff recognised the positive impact this openness had on the quality and safety of care provided.

Staff had opportunities to share concerns anonymously through regular staff satisfaction surveys. However, those we spoke with told us they felt able to raise concerns openly and did not feel the need to remain anonymous. This demonstrated a culture of trust, transparency and supportive leadership within the service.

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 management team demonstrated a clear commitment to equality, diversity and inclusion within the workforce. They described how reasonable adjustments had been made to support staff with disabilities. For example, where staff had trouble pushing wheelchairs, they were allocated to people who did not require this level of physical support. This ensured staff were able to work safely and effectively while meeting people’s needs.

Staff told us they felt supported by the management team and reported having a good work‑life balance. They said they felt respected and that their contributions were valued. This helped promote staff wellbeing, engagement and a positive working culture within the service.

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.

Systems of governance were in place within the service and provided a framework for oversight and quality assurance. We saw evidence that the nominated individual was actively involved in the service, including completing audits and providing regular support to the management team. This demonstrated leadership engagement and commitment to monitoring the quality of care provided.

However, we identified shortfalls in governance arrangements. The service had not submitted statutory notifications to the Care Quality Commission for all safeguarding incidents that had occurred. This meant the regulator had not always been promptly informed of events that affected people’s safety. The failure to consistently meet statutory reporting requirements indicated that governance systems were not always effective in identifying and addressing regulatory responsibilities.

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.

We saw evidence that the service worked in effective partnership with external organisations to support people’s care. The service worked collaboratively with the local authority, including taking part in regular reviews and escalating concerns appropriately where there were changes in people’s needs or safeguarding issues.

This partnership working helped to ensure people received coordinated, responsive support and that risks were identified and addressed in a timely way.

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.

We saw evidence that the service had effective processes in place to learn from incidents. Where incidents occurred, learning was identified and shared with staff to support improvements in practice and reduce the risk of recurrence. This helped to promote a culture of continuous learning and improvement within the service.

During the inspection, the management team responded promptly and positively to concerns that were shared with them. They took immediate and appropriate action to address these issues, and we were satisfied that concerns were resolved effectively. This demonstrated a proactive approach to improvement and a commitment to delivering safe, high‑quality care.