ISSAC

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 inspection, we rated this key question good. At this assessment, the rating has remained 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 promoted a positive, person-centred culture that was understood and demonstrated by staff across the service.

People and their relatives experienced this positive culture in practice and spoke positively about the care and support provided. Feedback reflected a service where people were treated with kindness, dignity and respect, and where staff worked to understand people's individual needs and preferences. A relative told us, “Overall, they’re very friendly and deliver a good standard of care. I rate them as good, I’m happy with what they’re doing and would recommend them to others.”

Staff understood the provider's values and were committed to delivering person-centred care. The positive culture within the service contributed to people receiving care from staff who knew them well, listened to their views and supported them to maintain their independence, wellbeing and quality of life. A person told us, “They are caring and kind, 100% they are doing the job.”

Management were compassionate, approachable and well regarded by people, relatives, staff and health and social care professionals. They were visible and actively involved in the service. A relative told us, “I would recommend them, I have a very good relationship with the manager.”

There was a clear management structure in place, which supported effective oversight and accountability. This included the registered manager, who was also the nominated individual, supported by an assistant manager and a range of dedicated roles, including a quality and compliance manager, medicines officer, HR and finance team, a training and assessment manager, and care coordination staff. Each role contributed to the smooth running of the service, with clear responsibilities for governance, staff support, training and care delivery.

A health and social care professional spoke positively about the management team. They told us, “I have found [name of management staff] to be thorough and proactive in their role. They communicate effectively with care management, ensuring that any changes or emerging concerns are shared promptly. They appear knowledgeable, well organised, and demonstrate a good understanding of the individuals they support.”

The provider fostered a positive and open culture where staff felt able to speak up and were confident their views would be listened to. Staff told us they felt comfortable raising concerns, and people and their relatives also said they were able to speak openly.

The service was a family-run organisation, with several family members working within the team. Staff told us this did not impact on their ability to raise concerns, and they felt any issues were addressed appropriately and fairly, regardless of who was involved. This demonstrated a culture of openness, fairness and accountability across the service.

The provider promoted an inclusive and fair workplace and supported equality and diversity within the staff team.

Staff spoke positively about the support they received from managers and told us they felt listened to and respected. The provider supported staff development and wellbeing through a range of initiatives. Staff were able to develop their knowledge and skills through training, funded qualifications and career progression opportunities.

The provider had effective governance systems in place to monitor the quality and safety of the service and drive continuous improvement. Processes such as audits, spot checks, observations, reviews of care records and feedback from people, relatives and staff were used to maintain oversight and inform service development. An electronic care management system supported real-time monitoring, enabling timely action where improvements were identified.

Relatives confirmed they felt listened to and valued, and that communication with the service was effective. A relative told us, “It’s well managed, they will always ring back if there’s a query…We do a quality survey regularly.”

The provider understood their responsibility to work collaboratively with others to ensure people experienced coordinated and seamless care. Staff worked in partnership with health and social care professionals to support positive outcomes for people.

A health and social care professional highlighted effective communication, coordinated working and timely responses to concerns, demonstrating the service’s commitment to partnership working.

The registered manager told us, “Multi-agency working is integral to providing quality care. Good relationships are paramount with the individuals we care for. The forging of these relationships has been beneficial for the organisation, staff and individuals, as well as providing partner agencies with an insight into our work.”

The provider demonstrated a commitment to continuous learning and improvement. Systems were in place to review care delivery, incidents and feedback to support learning and service development. An electronic care management system enabled information to be reviewed in real time, supporting oversight, reflection and timely action where improvements were needed.

The registered manager told us they actively sought feedback using a range of approaches, including spot checks, observations and surveys, to support ongoing development. They explained that feedback was regularly reviewed and used to inform changes and improvements to the service. This approach supported a culture of continuous learning, where reflection was encouraged and where people’s experiences directly influenced how care was delivered.