243 Church 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 changed to outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 89 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The statement of purpose contained detailed information about the aims and objectives of the service, with clear information about how the provider would fulfil these objectives. For example, it was stated in the objectives, ‘We will provide care and support that is grounded in core values of compassion and respect’. This was then followed by information about how the provider intended to achieve this, describing the training staff received and the systems that were in place to ensure the core values were achieved.

We observed these values were embedded in daily practice. Leaders and staff consistently demonstrated behaviours aligned with the provider’s vision, ensuring people were supported with dignity, respect and compassion. Staff showed a strong understanding of the service’s aims and applied these in their interactions and decision-making, reflecting a shared ownership of the provider’s culture.

Governance systems were effectively used to support and sustain this culture. Leaders carried out regular audits which were directly linked to a dynamic improvement plan, with clear tracking of progress against identified goals. This proactive and structured approach enabled both leaders and staff to identify areas for development and drive continuous improvement. As a result, there was sustained alignment between the provider’s stated values and the care delivered in practice.

This strong, values-driven and inclusive culture resulted in a motivated workforce and consistent delivery of high-quality care. People experienced care that was compassionate, responsive and reflective of their individual needs, demonstrating the positive impact of a well-led service with a clearly shared direction.

The provider demonstrated exceptionally capable, compassionate and inclusive leadership at all levels. Leaders had a strong understanding of the context in which care, treatment and support were delivered and consistently embodied the values and culture of the organisation. They demonstrated high levels of integrity, openness and honesty, and were well respected by staff due to their knowledge, experience and credibility.

Leaders were highly visible and approachable, creating a supportive and psychologically safe environment where staff felt confident to seek guidance and raise concerns. This strong leadership presence improved staff confidence and competence, which contributed to more consistent and responsive care for people. Staff were encouraged to escalate concerns and seek advice when needed, ensuring people received timely and appropriate support. For example, care planning guidance reflected a proactive and supportive leadership approach, empowering staff to recognise and respond to early signs of anxiety and seek senior support to ensure people’s emotional wellbeing was maintained.

Leaders had a detailed understanding of people’s individual needs and preferences and were actively involved in the day-to-day life of the service. We observed warm, respectful and positive interactions between leaders, staff and people, demonstrating leaders led by example and fostered a culture of kindness, respect and inclusion. Their visible engagement helped to embed high standards of care and ensured that people’s experiences remained central to decision-making.

Leaders actively promoted an inclusive culture where people, staff and relatives felt valued, respected and listened to. Staff described feeling supported and included, and there was evidence leaders recognised and responded to individual needs within the team, helping to create an environment where everyone could contribute. This inclusive approach strengthened team cohesion and supported the delivery of person-centred care.

There was a shared commitment across leaders and staff to continuously improve outcomes for people. This was reflected in their consistent behaviours, collaborative working and positive engagement with people, relatives and partners.

Staff feedback further demonstrated the strength of leadership. Staff told us that they get good support and guidance from their leaders.

Overall, leaders created a culture that was not only compassionate and inclusive but also enabled staff to perform at a high level. This resulted in a motivated workforce and consistently high-quality, person-centred care for people using the service.

A staff member told us, “I feel supported by managers. They listen to you, and if I needed anything at work or at home they'd help.”

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

There was a clear policy which explained to staff how they could speak up and raise concerns both internally and externally. Staff we spoke with told us they would feel comfortable and supported to speak up if they had to and told us they could talk to leaders about anything.

A member of staff who was not in a leadership position was identified as the lead for speaking up, and they demonstrated knowledge of the provider’s policy for freedom to speak up. Staff were invited to share any concerns they had confidentially with the named member of staff who could then support the staff member to escalate their concerns. This showed the provider had committed to providing staff with an opportunity to raise any concerns in a confidential and impartial way.

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.

There were policies in place for equality and diversity and a recruitment policy. These policies were informed by legislation such as the Equality Act 2010 and Human Rights Act 1998 which pertained to equality and diversity.

The provider had a diverse staff group and made reasonable adjustments to meet staff needs. For example, by being flexible around working patterns and annual leave to accommodate people’s cultural needs such as religious festivals.

A recent anonymous staff survey showed that staff felt leaders valued them as an employee.

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

Leaders were visible, led by example, and spent meaningful time with both people and staff. Leaders balanced managerial responsibilities with hands-on care. This created a culture of mutual respect where staff worked as a team. It also promoted shared responsibility and ensured leaders had a clear understanding of the day-to-day challenges within the service.

Detailed audits were completed for every aspect of the running of the service, and at every level of responsibility. There was an exceptional level of monitoring of quality, care and performance. This was evident in the number of audits leaders carried out, with attention to detail in all areas of people’s care, including areas that go above and beyond what would normally be expected. For example, the provider had a detailed dignity audit, which measured outcomes such as whether the means of communication in place for people were suitable, whether people had been involved in care planning, and whether they are given choice. These measures of dignity were judged by leaders making direct observations of interaction between staff and people. This meant leaders showed a clear commitment to quality care in all areas of the service, rather than just the expected indicators.

To further embed quality, the provider commissioned an external auditor to audit the systems and documents. This showed the provider operated a culture of openness where they welcomed external scrutiny of governance and record-keeping.

Sustainability and continuity were considered and embedded within the service. The workforce was highly skilled and knowledgeable, and leaders had ensured responsibility and capability were shared across the team. For example, by giving staff members responsibilities such as being a lead for wellbeing, or keyworker for people who they have a particular rapport with. This reduced reliance on any single individual and supported resilience within the service. Staff were empowered to make decisions and respond effectively to challenges in line with the provider’s values, ensuring continuity and consistency in care delivery.

This strong and proactive governance framework enabled the provider to maintain high standards, respond effectively to risks and drive continuous improvement. As a result, people consistently received safe, effective and high-quality care, demonstrating the impact of a well-led and sustainable service. For example, one person came to the service with an extremely limited diet. Through monitoring outcomes and care planning, the provider supported them to gradually introduce new foods to their diet, leading to them being more willing to try new foods and enabling them to eat a healthier and more rounded diet. This positive outcome was possible due to the systems of governance that were in place, as these systems underpinned all aspects of care planning and monitoring outcomes.

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.

Leaders knew local healthcare services well and made referrals to them when this was required. Leaders participated in regular reviews of people’s health and wellbeing with the GP. There was regular communication which was recorded in people’s care records.

Leaders told us about a recruitment fair which they held in a local pub. This attracted interest from the local community and led to the provider being able to recruit new staff members who lived local to the provider.

Leaders sought feedback from people, relatives and professionals involved in people’s care to improve the overall quality of partnership working and communication. This showed the provider was committed to monitoring and improving quality by seeking feedback from all stakeholders in the service.

The provider demonstrated a strong and embedded commitment to continuous learning, innovation and improvement, with leaders actively promoting creative approaches to achieving equality of experience, outcomes and quality of life for people. This extended beyond the organisation, with the provider contributing to wider safe practice and continuous improvement within the sector.

There was a highly effective, intelligence-led approach to learning from incidents. The threshold for recording incidents was intentionally low, resulting in a rich source of information about factors impacting people’s wellbeing. Leaders used this data proactively to identify patterns, particularly for people who were unable to communicate their needs verbally. This enabled staff to anticipate triggers, adjust care approaches and prevent escalation, leading to measurable reductions in incidents and improved outcomes for people. This demonstrated a culture where information was not only collected but actively analysed and translated into meaningful improvements in practice.

Leaders had established innovative and reflective learning systems to ensure training was effective and embedded. Staff completed structured self-reflection following training, encouraging them to evaluate learning, identify gaps and highlight further development needs. This approach went beyond compliance and ensured training remained dynamic, personalised and responsive, with a clear focus on how learning translated into improved care.

Supervision and appraisal processes further reinforced this culture, providing purposeful opportunities for reflection and professional development within an environment of trust and openness. Staff were supported to critically reflect on their practice, recognise strengths and identify areas for improvement, which enabled continuous enhancement of care delivery.

A range of well-integrated governance and engagement processes ensured learning was consistently embedded across the service. Regular team meetings, quality meetings and feedback forums for people, relatives and staff created multiple opportunities to share learning, review performance and drive improvement. Leaders used these forums effectively to synthesise information, identify trends and implement timely actions, demonstrating a responsive and forward-thinking approach to quality assurance.

Leadership was visible and values-led, with the registered manager taking direct responsibility for delivering training, such as Positive Behaviour Support (PBS), to ensure consistency and relevance. This contributed to a skilled, confident workforce capable of delivering high-quality, person-centred care.

Overall, the provider demonstrated a mature, well-embedded learning culture, where innovation, reflection and continuous improvement were integral to everyday practice, resulting in sustained improvements in safety, quality and outcomes for people.