Excellent Health Care

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.

Relatives told us they and their family members were happy with the care provided, with comments including, “Staff are kind and caring. I’m happy with the care delivered” and “They do their best. I’m very happy.” The provider had developed a strategy, vision and core values document for the service which identified objectives for how these would be achieved. This was shared with staff. Staff told us they felt supported by the senior staff, with staff members commenting, “Since I started to work for the company I have been welcomed so effortlessly. The office team are very kind, warm, approachable, respectful, understanding and ensure that we are always doing well” and “I really admire the office staff how genuine and respectful they are to me.”

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.

Relatives told us they felt the service was well led, with their comments including, “A well run service. Gaps in calls are managed”, and “A well run service? Yes, I can call them. I know who my contact is.” A staff member told us, “The company values professionalism, provides proper training, encourages respect and dignity in all care provided. They offer compassionate, reliable and person-centred support.” Relatives confirmed they knew who to contact if there was a problem and they felt confident raising any issues. The registered manager had appropriate experience in relation to proving care. The provider had developed a range of policies and procedures which were regularly reviewed to ensure they reflected current legislation and best practice. The registered manager said the policies were circulated to staff with a specific policy selected each month to be discussed during supervision meetings.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a policy on whistleblowing and processes for staff to raise questions and concerns. Staff felt confident to raise any concerns with senior staff. Relatives were aware of how to raise any concerns about the care provided.

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 provider had policies to ensure staff were recruited and supported in line with legislation. The registered manager explained there was an employee of the month scheme based upon positive feedback from people, relatives and professionals. Staff were supported to practice their faith and celebrate religious and cultural events. The registered manager said they recruited from the local community through visiting mosques and community centres where they helped people who might have an issue with securing a job. They tried to recruit people to meet the language, religious and cultural needs of the people they were supporting.

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.

The provider had a number of quality assurance checks and audits to monitor the service and the care provided. These included monitoring of medicines administration records, complaints, arrival and departure times for visits, care plans and staff records. The registered manager explained, if any issues were identified, an action plan would be developed. The provider had developed a contingency plan which provided guidance on how to keep the service running in case of an emergency.

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 provider worked in partnership with organisations to help support people with their health and wellbeing. These included GPs, district nurses, occupational therapists and mental health professionals. They also worked with local authorities and their social services 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, outcomes and quality of life for people. They actively contributed to safe and effective practice and research.

The quality of the service was monitored through a number of audits. People and relatives were asked for feedback through regular surveys and review meetings to identify any issues with the care. Staff were also asked for feedback though team meetings, supervisions and surveys. The information was used to identify possible improvement to the service. Staff completed a range of training courses to keep them up to date with best practice. Following an incident, accident, complaint or safeguarding, the lessons identified from the investigation were shared with staff to improve the care being provided. The policies the provider had developed were regularly reviewed to ensure they were up to date and were shared and discussed with staff.