Greenways

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 Inadequate. 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 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.

There was a shared ethos amongst the staffing team. Staff were visibly proud to work at the service and with the people they had been supporting for many years. The deputy manager told us, “After our last CQC visit, it’s become a routine for us to increase our care and culture. We knew what we were doing before, but we had to sit down and reassess everything. After that we’ve discussed the enhanced level of care to people. We now have the right perspective in terms of activities which are person centred for each person.”

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 felt the management team were approachable and supportive. We observed in the employee satisfaction survey from 2025, 100% of staff said they felt there was an open-door policy to the management team.

The registered manager told us, “When I’m here I come in and have breakfast with them all. I ask if there are any concerns individually or they’ll ask to speak to me privately. My phone is on regardless. I’m always contactable. It’s important to make sure they feel we are approachable, and I feel they are.” The deputy manager added, “I picked up a lot from [registered manager], he relates to all staff, it doesn’t matter who you are. I know staff well, so I can see if their body language is off, I will ask if they want a chat.”

The registered manager had displayed their passion in supporting the people they worked with to ensure better outcomes for them. For example, 1 person was running low on funds due to the cost of living rising. The registered manager had an electric charging port installed at the service for the service’s own electric minivan and supported the person to purchase their own electric car. The registered manager told us, “We bought an electric minivan so had to have the charging port anyway, so we’re not going to charge [person] for charging his own vehicle.” Relatives felt the management team were reliable and supportive. One relative said, “The managers are very good. If we have any problems, I just need to make a call, and they sort it.”

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

Information on how to whistle blow or raise concerns were placed around the service for staff. The quality manager also informed us, “Theres an annual survey sent out to staff. They can do that anonymously. There’s a suggestion box too.”

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 quality manager told us, “There’s so much training around equality and diversity as it is. Rotas and allocations are checked to ensure they’re given out equally. It’s constantly having that communication so they can reach out and tell us if there is an issue.”

Adaptations were in place to ensure information for staff was in their first language if needed to ensure policies were fully understood. The service also did different themed weeks based around foods from different cultures. This had included themed weeks such as Caribbean and Chinese. This had encouraged staff as well as people to be aware of and explore other cultures.

The provider had improved processes to have clear responsibilities, roles, systems of accountability and good governance. However, further work was required in some areas to ensure these were fully effective in their use and embedded within the service to be able confirm the risk of impact to people was minimised.

On the whole, improvements had been made at the service following our previous assessment.

The service had made improvement to policies and procedures so that staff understood expectations.The quality manager had recently been promoted into their role. They informed us that a minimum of 5 audits were completed each year which were based around different topics, such as medicines and finances. They told us, “We like to be seen as a supportive role, if there’s anything we can support them to implement at the time we do that. We give feedback at the end of the day and then send them a report in 2-3 weeks after that. Then we ask them to complete a quality improvement plan and then have a meeting to go through this.”

At our last assessment, we had identified night audits had not been completed to ensure staff on night shifts were fulfilling their role safely and effectively. We observed the provider had now implemented this, and any actions identified were worked upon.

The service worked closely with both Surrey and Sussex local authority. Both local authorities had visited the service to assess their quality and reported on their findings to the management team. These were on the whole positive, but where small areas for improvement had been identified, it was evident the management team had worked to implement these.

There were still elements of quality governance systems that required further work to ensure they were completely effective. For example, a medication audit completed in January 2025 stated that levels of support needed to be included in people’s medicine care plans and profiles. We observed during our assessment that this had been completed. However, the audit had not identified the missing body map missing from one person’s PRN protocol. Therefore, the audit had not been fully effective in its use. Governance audits had also not identified the concerns we identified around staffing levels in the community and at night, and accident and incident analysis not being individual and comprehensive. However, the management team were responsive to these findings and made the necessary changes immediately where possible.

We observed from staffing rotas that some staff would complete a 15-hour day shift and then be the sleep-in member of staff that night, followed by another 15-hour day shift the next day. Whereas typically this would be acceptable, sleep-in staff were often woken up to support the waking night staff member with managing people’s high anxieties and behaviours. One staff member told us, “This can happen 3-4 times a month roughly. We also have to support [person] at night when it rains as the sound triggers him. We have informed social services that we need extra funding for nights for this.” Therefore, the provider could not be assured that sleep-in night staff were receiving an appropriate night’s sleep to be able to be effective in their role the next day due to people’s needs. Following our assessment, the management team changed the staff requirements at night so both staff members were waking night. This therefore reduced the risk of staff not receiving an adequate break between shifts to support people safely.

We could not be fully assured people were being supported by the correct number of staff when accessing the community due to conflicting information between people’s care plans and the information given by the registered manager. People’s care plans stated they required 2 members of staff each when accessing the community for activities and social events. However, we identified on several occasions, 3 members of staff were supporting 2 people when accessing the community. Furthermore, during the first day of our onsite assessment, 3 members of staff were supporting 2 people whilst swimming. The registered manager told us this had been agreed by the funding authority but was unable to provide evidence of this. Although we found no impact of harm to people, this demonstrated that without thorough documentation from the local authority in this area it would appear staff were not being deployed to support people in the community which could leave people at risk of harm.

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.

Staff had a good rapport with local charities and organisations in order to provide holistic care to people. The registered manager told us, “We have a good relationship with the cycling centre. We’ve been using them for 5 years. And a good relationship with the trampolining centre. If they have any concerns they will pick up the phone and tell us, like telling us the best time to come when it’s not as busy. We have good relationships with the financial assessments and safeguarding team at Sussex. They’re very responsive if we need funds for anything they (people) need.”

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 management and staffing team had worked hard to implement the improvements needed identified at our last inspection. The registered manager told us, “Since the last inspection we’ve turned the negatives to the positive. It helped us to develop and come where we are. We weren’t evidencing it before, but we are now. We’ve got more individual activities too.” There were plans to further improve the service. The quality manager told us, “We are going to implement oral care and sepsis champions in the future, so we’re sourcing training for that.”