GFI@112

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 newly 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 people’s safe care and treatment governance at the service.

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.

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.

Leaders had a good understanding of people’s human rights, and staff confirmed they felt listened to when sharing ideas and feedback. Staff had a good knowledge of the service’s aims “Aspire, Care, Respect and Partnership” and shared vision. Staff told us they demonstrated these values every day by “putting the person at the centre of my practice, promoting their rights and independence, supporting them to be part of their community, and working with others to help them live the life they choose.” This meant people received a consistent service from staff who shared the same values.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, however, they did so with integrity, openness and honesty and embodied the culture and values of their workforce and organisation.

Leaders had not consistently identified areas of concern relating to the quality of the service or established clear priorities for improvement. They did not always demonstrate they had the full range of skills, knowledge and experience required to ensure people received safe and effective care.

However, the provider was responsive to feedback throughout the assessment process. They were open and transparent about areas identified as requiring improvement and developed an action plan to address these. Staff told us they felt leaders were approachable and inclusive, and that they reflected the values of the service in their day-to-day interactions.

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

Staff told us they felt confident they could speak up, and knew how to access the up-to-date whistleblowing procedure. Team meetings and supervision provided a supportive space for staff to raise concerns and ideas. A staff member told us, “When issues are raised, I do see changes being made afterwards, for example, updates to support plans, clearer communication, or adjustments to routines based on feedback from the team.”

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.

Staff told us they felt treated equally and fairly by the provider. They told us, “The manager is approachable and easy to communicate with. They usually pick up [the phone] when needed and provide assistance”, and “The service promotes a working environment where everyone is supported and given equal opportunities.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Systems and processes were not sufficiently established to enable leaders to identify and address concerns within the service. The provider did not carry out formal, recorded quality assurance audits to assess the effectiveness of the service or to ensure people’s needs were consistently being met. Audits created for the purpose of our assessment did not identify all safeguarding, complaints, accidents and incidents that had been recorded.

Audits of medicine administration had not been undertaken, meaning the provider could not be assured that medicines had been administered correctly, putting people at increased risk of serious harm. A medicines audit created for the purpose of our assessment identified gaps in medicines administration.

Information about risk was not assessed to identify trends or themes. Where leaders had reviewed an individual’s recorded incidents against the same member of staff, no documented investigation, lessons learned or actions to be taken were available, meaning that the person and staff were at increased risk of harm re-occurring.

Leaders did not have effective oversight of staff performance, as they did not carry out spot checks or observations of staff interactions with people they cared for. Where care plans had been reviewed, there was no clear system in place to measure or record compliance, meaning the provider could not demonstrate how they assured themselves of the quality and safety of care delivered. Training matrixes were not consistent, meaning the provider could not be assured what training staff had and had not undertaken.

Records did not demonstrate effective communication during transitions of care. For example, staff did not record the detail of handovers from other providers into their care, nor was there consistent documentation of information shared with family members at the end of visits. This meant the provider could not be assured of whether important information such as health deterioration had been communicated, putting people at increased risk of serious harm.

Although we did not identify any impact on people, there was no clearly defined governance structure to support effective oversight or to hold leaders accountable for addressing issues within the service. As a result, the provider could not be assured of the overall safety and quality of the service and met current best practise in line with ‘Right Care, Right Support and Right Culture’.

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 service was a part of the Restraints Reduction Network, which is a network of organisations and individuals committed to eliminating the unnecessary use of restrictive practices. People were supported to access the community in line with their care and support. The service requested training from professionals to improve staff knowledge. Staff told us, “The company is well run, they are always in contact with parents and staff.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Records did not always document continuous learning from safety events, staff debriefs safeguarding, quality audits, and care record audits. Themes and trends were not identified as a whole so there were missed opportunities for the provider to focus on improvement. The provider completed an improvement plan during the assessment period as a result of our feedback.

However, staff were offered the opportunity to undertake care qualifications funded by the provider. Staff felt they were encouraged to contribute to people’s care and changes were made as a result.