15 School Street

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 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.

Staff consistently described the service as one where people’s wishes and preferences guided the support provided. The vision was to promote independence and creativity in care, with flexible approaches tailored to each person. There were no rigid structures; instead, the service was led by the people it supported.

This ethos was reflected in staff feedback, with one team member stating, “I would definitely recommend living or working here.” This highlighted a positive culture and shared commitment to delivering inclusive care that responds to the needs people living 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 the management team were approachable and responsive. One-to-one supervision sessions were used not only to discuss work performance but also to explore health needs, reasonable adjustments, and strategies to support staff in remaining well and engaged at work.

The team culture was positive and collaborative, with staff expressing pride in the service. One staff member said, “I think it is an amazing service, supporting people to live full lives.” Another staff member said, “I would recommend working and living here, it’s such a fantastic place.”

Concerns raised by staff were listened to and acted on promptly, and leaders were described as supportive and compassionate who knew the people who lived at the service well. This created an environment where both staff and the people supported were respected by the management team and provider.

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

Staff were confident in raising concerns when needed. One staff member said, “It’s important we speak up if we had concerns as the people need us to look out for them and protect them. I have no problems in sharing my thoughts with the team and manager as we come up with ideas together.” This demonstrated a culture of openness and integrity within the service.

Staff spoke positively about the quality of care provided. One team member stated they would be happy for their own relative to live at the service, expressing pride in the compassionate and person-centred support offered. This showed staffs’ commitment to delivering good quality care.

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 training records showed staff received Equality, Diversity, and Human Rights (EDHR) training and we observed their understanding of this in their support provided to people. Staff understood different cultures, races, and identities, and this was embedded in the service’s values and approach. The provider’s values and objectives supported initiatives such as Lesbian, Gay, Bisexual and Transgender (LGBT) meetings to promote inclusivity and awareness.

The inclusive culture within the service helped to ensure all staff felt valued and respected, and the care delivered was reflective of the diverse needs of both the workforce and the people supported.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We viewed regular audits which were carried out to monitor the quality of care and ensure the service met regulatory standards. The assistant manager completed weekly and monthly checks, followed by quarterly audits carried out by the registered manager. The audits were aligned with CQC’s Quality Statements and Regulations, which ensured compliance was maintained and helped to drive ongoing improvement. Clear action plans were created with set timelines, allowing the service to track progress and maintain oversight. This demonstrated a commitment to accountability, learning, and delivering a good standard of care.

Accidents and incidents were recorded in detail, which allowed staff to reflect on their practice and manage risks effectively. The provider planned to distribute their annual feedback forms to people using the service, their relatives, and other representatives. This demonstrated a culture of ensuring everyone’s experiences and views were heard and used to drive improvements in care and support.

The registered manager told us how they continuously updated their knowledge and skills. The registered manager attended regular meetings to share practice updates and learning, including through Skills for Care and collaboration with other registered managers. The service also maintained strong community links, with weekly social engagement locally, which enhanced inclusivity.

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.

Staff regularly engaged with local health professionals, advocacy groups, and the wider community to ensure people had access to a broad range of services and opportunities. For example, the staff supported people to engage and feel part of their local community by regularly attending the local church, shops and places to eat. This reflected a commitment to person-centred care and improving outcomes through access to health and community services.

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.

Staff were encouraged to reflect on their practice and share ideas to enhance the quality of care provided. Regular training, team discussions and supervisions were used to identify areas for development of the service provided and personal development.

The provider had a strong staff group who were recognised through initiatives such as the Well Awards. Staff wellbeing was supported through access to a Welfare Hub, mental health support, occupational health services, and a confidential advice service.