Home Also known as Head Office

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• 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 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.

Policies were in place covering equality and diversity, and the registered manager was able to tell us how they met the needs of both staff and people with regard to this. For example, people were supported by staff with a shared cultural heritage. Staff rotas were drawn up taking into account individual staff’s specific circumstances.

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.
The service was run by the registered manager, who was also the owner of the business. They were supported in the running of the service by 2 care-coordinators. The registered manager told us they had an open-door policy towards staff contacting them. Staff we spoke with were positive about the organisation and the support they received from senior staff. A member of staff told us, “It’s a good place [to work]. They [senior staff] always support us and listen to us.” The same staff member said of the registered manager, “They are a very good manager, whenever we need anything, they help.”
 

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

People and staff were able to speak up. There were systems in place to facilitate this, such as complaints and whistleblowing procedures. Staff team meetings were held which gave staff the opportunity to raise matters of importance to them and staff also had regular 1:1 supervision meetings with a senior member of staff. There was an annual survey of people and their relatives which gave them the opportunity to provide feedback on the running of the service.

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 a policy in place on equality and diversity to guide practice in this area. Staff told us they were treated fairly by their employer. Staff recruitment was carried out in line with good practice as regards equality and diversity.

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 various quality assurance and monitoring systems in place. These included six-monthly surveys of people who used the service and their relatives, along with staff surveys. We saw the most recent surveys contained mostly positive feedback about the service. Various audits were caried out, for example, in relation to medicines records and accidents and incidents. Care plans were subject to regular review. As previously mentioned in the safe section of this report, the provider had not always identified shortfalls, for example in relation to medicines records. However, they did address these issues shortly after our inspection.

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 registered manager confirmed that they were working with various local authorities. They also worked closely with various healthcare professionals including GPs, Urgent Community Response Team, Occupational Therapists, and social workers. The provider also worked in partnership with organisation that provided support with staff training.

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.

There was a focus on continuous learning and improvement. For example, staff undertook regular training to help them develop in their role. Accidents and incidents were reviewed to see what learning could be derived from them. The provider was focused on improvements to the service and how it was run. For example, the registered manager told us they were developing a concise care plan for each person covering the essentials staff needed to know if they were providing cover at short notice to a person for the first time.