Winslow

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 requires improvement. At this assessment the rating has remained requires improvement: this meant the management and leadership were inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to governance at the service.

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 processes in place to engage with staff, people living at the service and their relatives to be part of discussions and make suggestions. Staff shared positive feedback regarding changes that had been made to allow staff to be more included and supported. Relatives spoke positively about the culture of the service and told us they had no concerns regarding the care and support their loved ones received.

The service had experienced changes in the management team. The current registered manager was moving to another role and a new manager was in post during our assessment and told us they would be applying to be the registered manager. There was a planned handover time period to ensure the service continued to be managed. Staff and relative feedback were positive regarding the deputy manager and registered manager and felt the service was well managed and they were capable and compassionate leaders. One staff member told us, “The manager and her deputy are readily available to listen to concerns and even weekends and off days.” Another staff member told us, “The management team is approachable and supportive. They encourage open communication.” The management team led staff to ensure care was provided to people that met their care support needs; however, robust governance processes were not in place in relation to the health and safety actions within external audits to ensure required actions were completed.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff and relatives told us they felt they had the freedom to speak up. One staff member told us, “Yes, I feel I can voice concerns without fear of reprisal. I know how to whistle blow using the organisation’s procedures. If I ever needed to, I would report concerns to external bodies if internal actions were inadequate.” The provider had a policy in place to guide staff on freedom to speak up.

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. Staff told us the service was a nice place to work. One staff member told us, “This a nice place to work because there is teamwork, support and a good working environment. Staff are competent and knowledgeable and the management are cooperative and approachable.” Staff had completed Equality, Diversity and Human Rights training.

There continued to be a failure to use governance systems to ensure health and safety actions were completed when required. We identified this at our last visit and found concerns with the management of health and safety at this visit. The manager did not have adequate oversight of checks to ensure the environment was safe. We found an outstanding action from the fire risk assessment completed in 2022 with no clear plans in place when this action would be fully completed. There was an action plan in place following the fire risk assessment, however, this did not have timeframes for actions to be completed or updates on progress. The registered manager told us the provider had an estates team who covered all the health and safety. The provider had systems and processes in place for the management team to have oversight of care planning, risk management, incidents and accidents and medicines management. Where stakeholders had visited and highlighted concerns and risks the provider did take action to address these concerns. The provider had systems and processes to obtain people and relatives views. The management team completed a record to show what actions had been taken in response to feedback. The was a system put into place by the management team called daily huddles. This was a virtual meeting with other managers from other locations and the operations manager to discuss key areas such as incidents and these meetings were recorded to show what was discussed and action taken.

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. Quality monitoring visits had been completed by the NHS integrated care board. Concerns and risks were identified on their original visit and a follow up visit had been completed and showed the provider had worked towards making the required improvements. People living at the service had opportunities to access their local community with their support staff.

Managers did not always focus on continuous learning, innovation and improvement across the organisation and local system. The wider leadership team had not ensured improvements had been sustained following our last visit and could not demonstrate they had effective processes for learning and improvement as we found similar concerns during this visit and found previous breaches in regulations had not been met. The provider did have plans in place to improve how their adult social care services were operating through updating policies and implementing new policies and procedures to support the type of services they were managing. The provider had implemented a new team to manage and progress this vision to enable more effective systems and processes.