R-H-P Outreach Services - South Norwood Hill

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 now 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 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.

People told us there was a good, open culture in the service and the registered manager was approachable. They said they were looked after by staff and got on well with other residents.

Staff also said there was a good environment in the home and if they needed any support, the registered manager or director were always available.

The service’s purpose and values were on display in the home for people, staff and visitors to refer to.
 

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.

Staff told us that the registered manager and directors were supportive, telling us they ensured they received regular training and supervision. Comments included, “It’s a good place to work” and “We get regular training opportunities.”

The provider was aware of their responsibilities as a CQC registered person, including when to submit notifications and other regulatory responsibilities. The provider’s latest ratings were on display in the home which is a statutory requirement.
 

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

People and staff told us their views and suggestions were welcomed by the provider.

The provider gathered the views of people and staff through regular key working sessions, handovers, supervision and meetings.
 

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.

People received their care and support from a diverse workforce. Staff told us they felt equally and fairly treated by the leadership and reported no experience or observation of discrimination.

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 monitored and improved the care and support people received. Managers completed a number of audits which provided assurance around safety and quality. These included reviewing care plans and risk assessments monthly, monitoring feedback gathered through meetings, medicines audits, health and safety checks and cleaning checks.
The provider was registered with the Information Commissioner's Office (ICO), the UK's data protection regulator. This registration indicates the organisation processes personal data and publicly commits to upholding data protection laws.
 

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 provider worked in partnership with other agencies and services to meet people’s needs. This included community nurses such as diabetic nurses, and the community mental health team.

People told us they were supported by community healthcare professionals such as the GP, nurses and other community professionals. Care records contained details of these professionals.
 

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. They actively contributed to safe, effective practice and research.

The provider promoted a learning culture within the service. Staff received on-going mandatory training and training to meet people’s specific needs. Incidents and near misses were reviewed to ensure lessons were learnt collectively, and quality audits were reviewed and acted upon. Leaders valued the input of others and actively sought the views and suggestions of people, staff and professionals to drive improvements.