Naylorsfield and Hartsbourne

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 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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities. The leadership team encouraged transparency and welcomed feedback. Staff told us the values and purpose of the service and told us there was a very open and honest culture within the service and the organisation. We observed staff interactions with people, which were kind, caring and respectful. This showed staff demonstrated the values of the organisation. The provider showed an excellent understanding of the needs of people and the challenges they may encounter. People’s wishes, preferences and aspirations were at the heart of their care and support, and people were fully involved in the design and delivery of their care.

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. We had discussions with the trustees and leaders and felt they demonstrated they understood the importance of strong leadership at all levels. They encouraged staff to be open and honest.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. One staff member told us, “I feel valued and part of this is being able to speak and lead ourselves as staff.” Processes were in place for staff to communicate their views on Naylorsfield and Hartsbourne.

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. Discussions we had with staff demonstrated they were highly motivated and valued the leadership approach of fostering an inclusive team. Team leaders told us they developed their managerial skills with support from the leadership team.

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 had robust systems in place to check the quality of care. Audits were carried out on a regular basis covering all aspects of care delivery. Actions from audits were recorded and followed up in a cycle of audits, actions and outcomes. People and staff were updated on actions through regular meetings. The provider worked in a way which was proactive and preventative. Good governance has led to excellent outcomes for people. Risks identified were shared with all relevant parties and measures put in place to mitigate these. The leadership team maintain excellent oversight of the service and ensure they keep on top of issues arising and actions taken. One health professional told us, “We found their response to incidents was compassionate and remained person centred. We felt the management made a notable effort to advocate for those in their care too, and as such feel that they are well led.”

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 a collaborative way with the local authority and other health care professionals. They actively sought out activities within the local community to enable people to be as involved as they would like to be.

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 had an extensive service improvement plan which included all actions that were either achieved or planned. Staff told us they were encouraged to be involved in discussions on how to improve the service for people.