Enchanting Care

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 64 (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 vision of how to sustainably grow the service without compromising safety and quality.

The provider promoted a positive and inclusive ethos. For example, they were good at promoting staff inclusion as well as meeting the challenges of diversity. Staff told us there was a culture of collaboration, where people and staff were listened to and communicated with. This demonstrated a pro-active approach to engagement with staff to improve the culture at the service. Staff received appropriate training in equality and diversity. Staff had a good understanding of the protected characteristics and the importance of these in practice.
 

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 Although there was a manager in place, supported by senior staff, they had not completed the registration process with CQC. The provider explained the action they were taking to ensure a registered manager application process was completed as soon as possible.

Staff told us leaders were open and honest, and they were able to contact them when needed. Senior staff had received appropriate training and ongoing development programmes relevant to their roles.
However, we identified some quality statements requiring improvement in areas such as risk and recruitment records and monitoring. Leaders had not independently identified and acted on these issues prior to our assessment. This meant some development was needed in their skills and knowledge to lead effectively.
 

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

Staff told us they felt comfortable speaking up and raising issues to senior staff. The provider had a whistleblowing policy in place and staff had received training in line with this policy. The provider demonstrated an open approach in their engagement with staff and acted to address their concerns when known. Staff knew who and what to report both inside and outside of the service and felt encouraged to do so by the provider. Staff told us, “They don't discourage you. At reviews/121 you can tell them if you are not happy about something or in between if needed.”
 

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. For example, the manager demonstrated how they made reasonable adjustments to staff’s working patterns and training programmes, to ensure staff were treated fairly and given appropriate support in their role. This included additional support for staff new to care or during induction and shadowing. Staff from an ethnic minority background told us they felt part of the team and well supported by the provider.

The provider had clear responsibilities, roles and systems of accountability to support good governance. However, internal audits were not always effective in identifying all risk and shortfalls to ensure they could always act on the best information about risk, performance and outcomes to improve the service. Audits were not sufficiently comprehensive to identify the risk and recruitment records concerns we identified. However, the provider worked during the assessment to rectify these processes and put in place appropriate oversight going forward.

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.

There was evidence of partnership working with key stakeholders, including commissioners, other providers and health professionals. For example, the provider worked closely with nursing teams to keep people safe and provide condition specific training for staff. Staff told us if they raised any concerns the office staff would follow up with professionals in a timely manner to get the support needed for people. Senior staff also told us they followed up with GPs to share updates. This helped to promote positive outcomes for people using the service.
 

The provider was motivated to work towards continuous learning and improvement across the organisation and local system. Although the provider was motivated to learn and improve the service for people, their overall ambition was at times limited by some internal audits that meant they might not always be aware of shortfalls to enable prompt improvement and learning.

For example, although the provider recorded and actioned concerns including accidents and incidents, there was no evidence of any trend analysis taking place to reduce the numbers of related incidents. From the information reviewed, falls were the most frequent incidents. Reviewing a person’s multiple falls for any pattern or trend would further aid any risk management plan to support staff and relatives to prevent future falls or reduce harm. We highlighted this to the provider who told us they would look into this going forward.

However, the provider had followed up concerns appropriately with good communication to both staff and relatives. The provider was very receptive to staff suggestions for improvements for people. Senior staff had regular review meetings with people and relatives, to ensure the service was meeting people’s current needs. There was evidence of learning and improvement with all of these.