SM Voice Advocacy 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 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 68 (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 service understood the challenges and needs of people being supported. The care people received reflected the service’s values and objectives as set out in their statement of purpose. The provider promoted a positive, open culture and inclusive ethos. The culture and direction of the service was driven by the RM who had the best interests of the people supported at the centre of all they did.
The provider used team meetings to ensure staff were aware of their values and what was important. Staff told us they were happy with the company and its values. 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.

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 leaders were open and honest, and they were able to contact them when needed. One staff member said, “(Senior staff) understood the challenges of supporting people with complex needs and have always been available as sounding boards and mentors.” Senior staff were receiving appropriate training and ongoing development programmes relevant to their roles. The registered manager had suitable qualifications and experience in adult social care including social work. The registered manager was very passionate about their service and encouraged staff to provide high quality care and support to people. This was reflected by the staff we spoke with. The registered manager knew what needed to be referred to safeguarding and the notifications needed to be made to CQC.

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 as the RM had an open-door policy. The provider had a whistleblowing policy in place including who to contact outside of the service when appropriate. 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.

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.
There was additional support for staff new to care or during induction and shadowing. Staff told us they felt well supported by the provider.
There were policies in place for equality which staff had access to. The provider had employed a diverse workforce mainly through the government sponsorship scheme.
Staff training was up to date for staff on the training matrix covering equality and diversity.

Although the provider aimed to have clear responsibilities, roles, systems of accountability and good governance, they were limited by their policies and clarity of their documentation.
The registered manager told us regular checks and audits were completed to monitor quality and risk in the service. These included audits relating to finance, medicines, daily care logs, and observing staff practice. There were also regular reviews of people’s care. However, it was not always clear how often these took place or what other areas were audited. For example, audits had not identified the concerns we found in relation to recruitment, medicines and staff training records and policies.
There was a suitable business continuity plan in place, although it did not include prioritising care for the most vulnerable of people supported. However, the RM told us they knew the level of priority support people needed .
The provider used feedback from people, relatives, staff and partners to learn from and improve the service. However, there was no evidence of an overall improvement plan in place to ensure all improvements and risks would be shared and monitored.
The provider also obtained feedback through compliments and complaints. There was positive feedback from professionals involved with the service which confirmed a good quality of care being provided to people including good oversight of people’s finances.

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, and health professionals. For example, the provider worked closely with social workers for reviews of care, deputies for people’s finances, and mental health teams for the best outcome for the people they support. Feedback from partners including social workers was very positive and highlighted good communication with the service as well as improved outcomes for people.
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 said they had regular review meetings with professionals especially if people go into crisis. This helped to promote positive outcomes for people using the service.

The provider aimed to improve through continuous learning and improvement across the organisation and local system.
The provider learnt from interactions with people and feedback from the mental health team to improve people’s PBS plans. This helped to reduce incidents and improve outcomes for people. The provider held team meetings to discuss improvements with staff and get their suggestions as to possible improvements for people.
However, shortfalls in internal quality and risk monitoring systems meant areas that required improvement might not always be identified and remedied.
The registered manager was open to any points raised by the inspector. The provider had started making improvements in response to our inspection feedback.