West Lancashire Short Break Services

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 71 (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 manager and staff had a shared vision, and there was a positive and caring culture which prioritised high-quality, compassionate and person-centred care. The manager said, “The main thing is people are safe and well-cared for, and have fun. I want them to enjoy their stays.” A staff member added, “I think there is a good ethos. It’s really caring.”

This aligned with the service’s principles, ‘selflessness, integrity, objectivity, accountability, openness and honesty’ found within the code of conduct.

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.

The manager was recruited safely and had clear roles and responsibilities, receiving the appropriate support from senior managers to develop within their role.

Staff spoke positively about the manager, confirming they were knowledgeable about issues within the service. A staff member said, “[Manager] knows their stuff and is very good. Concerns are addressed very quickly, everything gets dealt with.” Another added, “If something goes wrong, we have help and guidance. They are always around to ask for help or for decision making.” Concerns about poor culture were addressed promptly.

The manager was visible, available and led by example. A relative told us, “They’ve just changed manager. They always look out to say hello and they take their time to chat with [person].”

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

The manager promoted a culture of speaking up. Team meetings and supervisions were held regularly, and staff were asked to contribute. A staff member said, “We have regular team meetings, and we are always being prompted to give feedback or share new ideas. The manager really seems to appreciate the feedback.” Staff confirmed concerns were acted upon and lessons were shared.

Policies were in place to support whistleblowing and staff who spoke up, and those that did received a timely apology in response to concerns raised.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for staff.

The service ensured equality of opportunities and experience for staff, including those with protected characteristics. Information about workforce diversity and their rights as employees was available to staff, and the service’s code of conduct stated, ‘equality and respect for all’.

Reasonable adjustments were in place to ensure information was made accessible. For example, company policies were available in a range of different languages and could be viewed on different coloured backgrounds for staff with dyslexia.

The provider’s systems did not always ensure good governance, but they had clear responsibilities, roles and systems of accountability and used these to manage and deliver good quality, sustainable care, treatment and support. They acted on information about risk, performance and outcomes.

There were concerns with the integrity of data in several people’s support plans, as information was not always robust or contemporaneous; and audits had not identified or addressed these issues. For example, people’s health, behavioural and communication needs and associated risks were not always recorded in adequate detail and several reviews were overdue. Capacity assessments and best interest decision making records had not been completed consistently.

However, the service had adequate arrangements for the availability and confidentiality of data, records, and data management systems. Systems were in place to ensure General Data Protection Regulations (GDPR) were maintained, and there were plans to improve GDPR further by digitalising records and introducing an electronic care planning system.

Staff carried out regular checks at the service and there was a good level of oversight from the manager. During the inspection, the manager explained they were in the process of reviewing current checks and audits, to streamline them and make systems for monitoring the safety and quality of care more effective.

Following feedback, the manager assured us support plans and risk assessments would be reviewed in full as information was being transferred onto the new electronic care planning system. Records relating to capacity and consent had also been scheduled for an update.

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.

The manager and staff were open and transparent, and collaborated with relevant external stakeholders and agencies. The manager attended meetings with other short break services to share learning and promote continuous improvement; and worked closely with local day centres and domiciliary services, sharing staffing or resources.

The manager organised annual open days to engage existing people, relatives, and others within the local learning disability community.

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.

The manager genuinely welcomed feedback, engaging positively in the inspection process and seeing it as an opportunity to improve the service, and people’s quality of life.

Staff were supported to prioritise their time to develop their skills around improvement and innovation. There were several ‘champions’ in areas such as safeguarding, nutrition and hydration and IPC; to support and offer guidance to the team.

The service had strong external relationships that supported improvement; and the manager confirmed there was adequate investment to improve the service and people’s experiences.