2 Millbrook Way

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 person centred care. 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.

The manager and staff worked with families and health and social care professionals to build a culture that focused on enabling to people to enjoy their lives. Staff spoke positively about the people they supported, and our observations showed people were happy.

Staff could give examples of how to support people using the least restrictive options and described strategies that provided positive outcomes.

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.

Feedback on the management team was mostly positive. One relative told us by email, ‘I cannot praise [manager and deputy manager] enough for their work with [family member]. They are both in regular contact with me and are always available to me should I need to get in touch with either. [Family member] loves to sit with the management team when they are able to and just be with them in their company.’

Staff spoke positively about the manager, confirming they were, visible and knowledgeable working alongside staff. A staff member said, “[Management] they help, they know people well. best managers I've had. It’s the best place I've worked at, truly, other places managers aren't seen.” Another added, “[Manager] is the best manager I have ever had. I feel comfortable telling [manager and deputy manager] anything.” They gave examples of when concerns about poor culture were addressed promptly.

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

Policies were in place to support whistleblowing, and the manager promoted a culture of speaking up. Team meetings and supervisions were held regularly, and staff told us they felt included and were able to share their views. One staff member told us, “[Manager] will 100% listen if I have a complaint.” A second staff member said, “Supervisions talk about welfare and how I'm doing at work and if there's anything else that I need.”

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 and procedures around equality, diversity and inclusion. Staff told us they were supported by the management team and felt they considered their equality, diversity and inclusion and treated everyone equally and fairly.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The providers systems to monitor medications were not consistently followed. Concerns we found related to the management of diabetes, medicine temperature checks and stock control had not been shared with management. The manager took immediate action and spoke with staff to ensure systems were robust and complied with in the future.

Governance processes and spot checks gave the management team oversight of the service. This ensured they acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Audits and checks were carried out to ensure the environment was safe. Fire, gas, electrical and water safety checks were carried out in line with guidance and issues identified were resolved.

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.

Management and staff worked closely with relatives, health and social care agencies, the local authorities and us (CQC) to drive improvement and meet people’s needs. Records we viewed and our experience of transparent conversations with the management team and information sharing confirmed this.

The provider encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Staff and management had a good understanding of how to make improvement happen. The approach was flexible and included identifying people’s changing support needs, measuring outcomes and impact.

The manager and senior management were able to explain how quality assurance systems allowed oversight of the service.