3L Care Limited

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 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 75 (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 ensured the shared direction of support placed each person at the centre of decisions being made about their lives. Most staff we spoke with told us leaders and managers were visible, accessible, and consistently available for guidance. Relatives and staff described a more inclusive culture. One relative said, “The new manager is like gold dust. She listens to me,” and another commented, “She doesn’t hide anything.” One staff member said, “A year ago we would have been rated inadequate by CQC. Things have changed so much for the better.” 

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. Leadership was becoming more structured, accountable and visible, with evidence of compassionate and inclusive engagement with staff, people and relatives. There had been a period of instability, but the current home manager and deputy manager were widely described by people, relatives and most members of staff as visible, proactive and open. Senior leaders within the wider organisation had also provided additional oversight during periods of instability. People’s human rights were embraced. Leaders had strengthened oversight systems. Although environmental audit systems still need to become more reliable, leaders showed awareness of past weaknesses and had a defined plan for improvement. 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The culture was moving towards greater openness and transparency where people, relatives and staff feel safe to raise concerns without fear. Leaders regularly engaged with people and their representatives. Staff showed a clear understanding of how to raise concerns, including whistleblowing procedures. Most staff described feeling more confident about speaking up under the current leadership, supported by an open-door approach and regular team meetings. In the past, some relatives described there had been a “closed culture.” One relative said, “I felt I couldn’t bring anything up.” More recent feedback indicated this had improved, with relatives reporting concerns were now listened to and addressed promptly. Where concerns had been identified, the issues were acted on rather than ignored.  

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. Relatives commented on the diversity within the staff team. One relative described staff as “trying their hardest to communicate well.” Supervision and competency processes apply consistently across different staff roles. Recruitment includes safer recruitment checks and probation periods to ensure fairness and suitability. Staff had training on equality and diversity with mandatory ongoing e-learning. 

The provider had clear responsibilities, roles, systems of accountability and governance. These were used to manage and deliver good quality, sustainable care, treatment and support. Governance systems had strengthened and were effective in supporting oversight of care. These included structured supervision, competency assessments, safeguarding systems and regular audit processes. The provider worked in partnership with the Local Authority and participated in professional forums to support continuous improvement. While some issues were identified during the assessment, including infection prevention and environmental concerns, the provider responded promptly and demonstrated the ability to identify, address and learn from these. Systems were in place to review and update care records and risk assessments, and these were aligned with staff knowledge and understanding of people’s needs. Training was embedded, relevant and valued by staff, supporting consistent practice.

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. Partnership working was structured and was improving with stronger engagement with external professionals and community links than previously. The provider worked with a range of healthcare professionals, including Speech and Language Therapists (SALT), Occupational Therapists (OT), epilepsy teams and hospice services. Professional partners we spoke with described a positive shift in partnership working. Staff attended hospital discharge planning and best interest meetings to help ensure care is joined up and consistent. The provider attended professional forums and worked with organisational quality teams.

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. The provider was moving from a reactive approach to a more structured system of governance and organisational learning. They had shown learning following previous safeguarding and medication incidents. Reflective practice forms had been introduced to encourage staff to review and learn from incidents. Staff described a greater sense of professional accountability. One staff member said, “I remain accountable,” showing ownership of mistakes. An external professional described the home manager and deputy manager as “responsive and engaged with improvement initiatives.”  The provider had submitted a proposal for structured clinical supervision aligned with Nursing and Midwifery Council (NMC) standards had also been developed at board level, showing forward planning. Incident records were detailed and showed that staff were open and honest about what had happened. The provider had made changes to the environment after near miss events to help stop similar incidents happening again.