Opportunities for Adults and Children

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 changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to the governance of the service. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

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.

Leaders fostered a culture of transparency, inclusivity, and safety, creating an environment where collaboration thrived. Organisational values were embedded in policies and everyday practice, supported by robust monitoring and review systems that ensured accountability and continuous improvement.Staff knew the aims and values of the organisation and the registered manager told us they covered the values of the service at staff’s induction and talked about them in supervisions and during training to ensure they were embedded in 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.

Leaders were approachable and committed to supporting staff in delivering person‑centred care. Staff we spoke with felt supported by the registered manager and senior team. Staff told us the registered manager was visible and approachable. The registered manager recognised that clear, timely communication and consistency in support were essential for staff to feel well supported, and was committed to maintaining open, accessible and supportive channels across the service and teams. They worked closely with senior staff to strengthen day‑to‑day coordination and ensure staff had the guidance they needed. These improvements were in progress and needed time to become fully embedded across all teams.

Staff and leaders expressed genuine passion for their roles. The registered manager described their intention to foster a culture of person‑centred care, openness and teamwork, and this was reflected in the feedback we received from staff.

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

The registered manager told us they operated an open-door policy and encouraged people, relatives and staff to speak up freely. The provider completed surveys of people and their relatives’ views and used the feedback gathered to make improvements to the service.

The provider had policies in place to ensure staff acted in an open and transparent way in relation to care and treatment if people came to harm. Staff were happy to speak up for people where required, listened to people’s concerns and acted on these if needed.

Staff were aware of how to raise concerns and mostly felt listened to, although a small number expressed that communication and support could at times be improved. The registered manager was working closely with senior staff to strengthen communication and ensure consistent support across the service. This included increasing their visibility in supported living locations where additional oversight or support was needed, helping to provide stability and clearer lines of communication for staff.

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. Diversity was celebrated, and inclusive policies ensured fairness and accessibility for all staff and people using the service. We saw various religious and cultural preferences were celebrated. Staff were equipped to provide culturally sensitive care for people.

Leaders engaged with staff regularly to gain their feedback and support them with their individual needs and circumstances.Staff mostly told us they were treated fairly, with respect and dignity, although a small number of staff indicated this was not their consistent experience. The registered manager was supporting the senior team to promote consistent, inclusive practice across the service.

Governance arrangements were in place, but they were not always effective in ensuring safe, high quality and sustainable care. The provider did not always act on the best information about risk, performance and outcomes, as risk management processes did not reliably capture or document all relevant information needed to guide staff practice. Although staff understood people’s risks well, a lack of detail in some risk assessments increased the risk of people receiving inconsistent support. Shortfalls were also identified in medicines management. The provider’s governance systems had identified these shortfalls before the assessment, and work was underway to make improvements. However, these improvements were still in progress and had not yet been fully embedded across the service.

Overall, while the provider was aware of these issues and had begun to address them, governance processes were not consistently effective in ensuring risk information and medicines guidance were sufficiently detailed, reliable or consistently applied.

The provider demonstrated an understanding of the scope of their registration and was taking appropriate steps to ensure it accurately reflected the care they delivered. Although their registration included service user bands for both adults and children, at the time of the assessment they were only providing support to adults. They had submitted an updated Statement of Purpose to remove children from their service user bands and were in the process of amending their registration accordingly. This showed a transparent and responsible approach to regulatory compliance.

Leaders and managers supported staff effectively, and staff were clear on their individual roles and responsibilities.

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.

Records showed leaders and staff worked effectively with health and social care professionals to meet people’s needs. Reviews had been completed with relevant healthcare professionals as people’s needs had increased and appropriate referrals made to occupational therapists, community nurses and GPs when needed.

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.

Continuous improvement was embedded in the service’s culture. Audits, reflective practice, and participation in learning drove improvement and enhanced care quality.

The provider also engaged with other local services and organisations to share learning, ideas and best practice. This collaborative approach enabled them to remain up to date with developments in the sector and continually refine their service. The registered manager shared examples of research the service had participated in, including involvement in sexual health research projects. This demonstrated a commitment to contributing to wider learning and improving outcomes for people both within the service and the broader community.