Support for Living Limited - 37 Barlby Road

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.

The last rating for this key question was good. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We identified a breach of legal regulations relating to good governance.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a positive culture which ensured people received person-centred care.

Staff told us the management team were supportive and approachable. We could see from records and talking with staff and the management team that there was a shared desire to provide the best service for people living there.

Staff demonstrated a commitment and genuine fondness for the people who they were supporting.

Most health professionals confirmed that the service provided was of a good quality. We were told “I have only seen kind and caring interactions towards [people using the service] and health professionals.I have no concerns.”

The registered manager told us the provider had systems to identify and address any ‘closed cultures.’ Staff showed they were able to speak up and raise concerns when needed.

The registered manager oversaw this and another service. They had the additional support of deputies at the service. We saw the registered manager knew the people at the service well and offered to support staff if an additional staff member was required to carry out other tasks.

An operations manager carried out quarterly audits of the service provided, and this service is part of a larger support of the organisation that shapes policies and develops strategies. This assessment identified areas where the management of the service could be more robust, and proactive. The provider could not evidence they had identified any areas of concern, including those we found at the assessment and found innovative methods to address these issues.

Staff told us they felt supported by the management team and the organisation.

The provider had systems for staff to speak up and raise concerns. Staff told us they felt able to do this and had done so. However, we found there were some issues that remained unresolved at the time of the assessment which were impacting on the way the staff team operated. We discussed this with the registered manager and provider who told us of the actions they had already undertaken. Following the assessment and a greater understanding of the impact on the team, the provider was able to tell us the additional support they were offering to the team to address these issues.

The provider supported workforce equality, diversity and inclusion. They had an ‘equality in employment’ policy which considered the legal requirements of the Equality Act 2010 and ensured staff were not unlawfully discriminated against. The provider monitored pay and promotions to ensure staff with diverse needs were treated equitably. Staff told us they were fairly treated.

Quality assurance processes were not always effectively used in identifying shortfalls in the delivery of care including those we identified during the assessment. For example, systems had failed to identify where improvements were needed with medicines management, infection prevention and control and safeguarding people’s rights.

The provider did not always ensure systems in place enabled staff to have sufficient guidance to manage specific behaviours of people using the service.. This impacted on the dignity of people living at the service, and highlighted lack of good governance at the service.

Following our visit to the service, the registered manager gave us a plan of how they intended to take remedial action and the timeframe for this. This included updating the recruitment policy to require asking for references from employment with vulnerable adults and children to ensure it was fully in line with CQC regulations; implementing audits to maximise good quality night care; introducing behaviour management logs to improve management and understanding of behaviours and more support for the staff team.

The provider carried out audits quarterly as did the commissioners of the service. The provider was open and transparent in providing this information.

There were a range of policies and procedures which reflected good practice and legislation. Staff were familiar with these.

When things went wrong, there were plans to show the action the provider took to resolve issues.

Staff worked in partnership with others to make sure people’s needs were met. They had regular contact with social and healthcare professionals to discuss people’s wellbeing and the support they required.

Staff also worked with others within the organisation to share good practice. This included updates from senior leaders and reviews of the work they were undertaking.

The provider promoted a learning culture. Staff undertook regular training and discussed best practice during team and individual meetings with their manager.

The provider was proactive when things went wrong, learning from audits and feedback from stakeholders. During our assessment, we discussed areas where improvements could be made. The registered manager and operations manager reflected on these and developed a service improvement plan with timescales for implementing changes and improvements.

The registered manager was familiar with changes in legislation and good practice guidance and could demonstrate how they were making improvements in line with ‘Right support, right care, right culture’.