First Point 24

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.

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 service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion. The service focussed on engagement with people and their communities gaining an understanding of their needs. The registered manager told us they had worked hard to change the structure and processes within the service to drive improvements. The registered manager told us, “We have worked extremely hard to change our processes to ensure they are more robust, and we now have effective and efficient systems in place. We are recruiting 3 additional senior staff members including a clinical lead to help with oversight and management.” The management had clear values and had developed a listening culture where staff felt they were available for them to talk to.

The service 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 management were clear about their roles and had the skills, knowledge and experience to perform their job. The registered manager told us they regularly attended provider forums and managers network meetings to continue to drive positive outcomes in the service. “A relative told us, “The manager is lovely and goes out of their way to make sure everything is ok. I would recommend them to anyone.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager had a policy and processes for staff to follow on ‘whistle blowing.’  We reviewed staff meeting minutes and saw they included information about the service as well as reminders about training, staff rota’s, safeguarding, incidents and PPE. However, there were no action plans completed to evidence how issues raised were to be addressed, dates to be achieved and if actions had been resolved or remained outstanding. The registered manager told us they would introduce this to their meeting minutes.

The registered manager held regular discussions with people to share their thoughts about how the service was ran and to discuss the support they received and if any improvements could be made. The service recently introduced a ‘Talking Hub’ initiative, providing people with regular phone calls to help reduce loneliness and make sure they feel connected and supported.

A member of staff told us, “We have regular meetings and supervisions with the manager which is a good opportunity for us to discuss anything with them. The manager invests a lot of time and energy towards us, and I really appreciate this. If I am lone working, I do not feel alone, I still feel part of a wider team as we are always given the opportunity to talk to each other and raise concerns.”

A staff survey had been sent out for staff to complete. The management collated results to analyse for any themes or trends. Management told us the survey results are discussed during staff meetings and supervisions.

The registered manager told us they had several systems in place to help them monitor outcomes for people. This included asking people for their feedback through meetings and telephone calls and the completion of surveys on their care experience. Surveyresults were analysed for themes and trends see where improvements could be made.

The service valued diversity in their workforce. The service worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. There was a policy in place to protect staff from harassment and bullying and a focus on protected characteristics under the Equality Act. The registered manager had developed an inclusive workforce and recognised the value of diversity amongst the team.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Improvements had been made since our last assessment and the service was no longer in breach of regulations. The management had established a number of audits which provided them with a good oversight of the service. The management had given staff a clear direction of their vision for the service. Staff understood their role and contribution in sustaining improvements. The registered manager had recently recruited a HR manager to support with staff recruitment and to ensure staff files are kept up-to-date and contain all the required information. A member of staff told us, “The manager is aware of their responsibilities and is responsive and proactive. I learn a lot from the manager as they are very knowledgeable and are always willing to share information with the staff.”

We received positive feedback from a health professional. They told us, “The manager and the whole team are approachable and when the team is not available there is always someone to step in. The service is being managed very well.”

The service 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 management and staff shared the same goal to provide positive outcomes for people. The management encouraged staff to discuss and share ideas for improvement and innovation. A health professional told us, “I feel the service is managed very well. The service communicates effectively, and we meet regularly for oversight, and we are able to contact the team if required.”

The service 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. They actively contributed to safe, effective practice and research. The management was actively supporting staff with learning and innovative ways of working at the service. Staff were encouraged to develop their skills and were supported to obtain nationally recognised qualifications. The service had a large training room with various equipment to help staff with face to face training. One member of staff said, “I have completed lots of training including the care certificate when I first started and continue to do regular trainings. There are always opportunities for growth and development.”