Centred Healthcare

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.

This is the first assessment for this registered service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.
 

This service scored 57 (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 equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.
The provider had faced challenges but always commended and supported staff. They demonstrated a strong understanding of compassionate care that they shared with staff.
The culture of the service was person centred, staff had confidence in their manager and felt safe to raise concerns.
The registered manager had a plan to restructure the service and implement electronic systems to improve recording and governance.
 

Leaders did not always have the skills and credibility to lead effectively.
The registered manager had not independently identified and acted in relation to the concerns we found during our assessment. They had not identified their own learning and development needs and did not act quickly to address concerns.
However, the registered manager had knowledge and experience, was open and honest and staff told us they were visible and available.
Staff told us “[registered manager] really good with us coming to her, yes feel supported, by fellow staff and by her as well.”

Another said, “Registered manager, provides support, quite lovely, I feel like I am valued because of the feedback I get, if I complain or am bothered, she gives me listening ear.”
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
One person told us “[registered manager] will say leave it with me I will get back to you and speak to [staff]. She does do that.”
One staff member told us, “We have group/team meetings, discussion and collaboration, feel comfortable raising concern and giving feedback, not a rigid meeting, freedom to say what's on your mind.”
Meeting minutes evidenced that staff were given the opportunity to speak up and that the registered manager enquired into their wellbeing. However, there were no minutes of meetings that involved the whole staff team. Meetings didn’t discuss recent incidents and were held infrequently.
Raising Concerns, Freedom to Speak Up and Whistleblowing policies were in place that staff had access to.
 

The provider did not always work towards a fair culture by improving equality and equity for people who worked for them.

Concerns were raised regarding the support arrangements and availability of breaks for a small number of staff, along with the pressure to provide continuous support without adequate contingency planning in their absence.

However, diversity and inclusion were valued in the workforce, and staff were supported to improve their skills and knowledge. Staff told us they work well as a team, and they do what they can to help each other.
 

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.
Audits had not been completed in line with their schedule. Some documentation we requested was not available and some documentation was out of date, missing information, not named, dated or signed.
It was unclear why some monitoring documentation was in place and who was auditing these. Some incidents and actions discussed with the registered manager had not been recorded. Some documentation was confusing with information completed in the wrong sections for example, body maps and fluid intake records. Medication audits did not identify gaps or errors on administration charts and medication competency checks were not completed annually as required.
However, there were plans to introduce electronic programmes to improve governance systems.
 

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.
Appropriate referrals had not always been made to external health and social care professionals where this was required for people. For example, when unexplained injuries were identified and when a review of moving and handling equipment was required.
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.
Audits had failed to identify gaps, and the service had not identified the need for all staff to be trained to support autistic people and people living with a learning disability.
However, the service had a plan to re-structure, implement new systems and invest in the service. The registered manager had previously attended relevant health and social care workshops online and read about changes to guidelines and policies. They had accessed support from other local managers to share knowledge and updates.