Affinity Trust - South West

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 good. At this assessment the rating has remained good. This meant the management and leadership was consistent. Leaders and the culture they created supported the delivery of high-quality, person-centred care.

This service scored 68 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider had a clear set of values and had engaged staff in understanding and embedding these. A review of the service’s culture had been completed, with actions identified for improvement.

Staff spoke positively about the people they supported and working for the service.

The provider did not ensure they had leaders at all levels who fully understood the context in which the provider delivered care, treatment and support.

Whilst they embodied the culture and values of their organisation, managers did not always have the knowledge or understanding to ensure the service provided safe and effective care in line with best practice guidance. For example, people’s changing needs were not always reflected in their care records and there were shortfalls in relation to staff training.

The registered manager also had responsibility for another of the provider’s services. They had not been overseeing Affinity Trust South West whilst another manager was in post. This manager left prior to our assessment, and during our assessment, the registered manager had resumed oversight of the service. They responded promptly to our concerns and demonstrated leadership in addressing the issues we identified. During the assessment, the management team were transparent, receptive to feedback, and took immediate action to address our concerns.

One staff member told us, “I think management listen. They’re approachable. If ones not here I can call another one.” Staff confirmed they had team meetings. One staff member told us, “We have team meetings every couple of months.”

We received mixed feedback from people’s relatives regarding the management of the service. One relative told us, “It seems to be run well, I don’t have any details [of managers], mainly I’d talk about lack of communication with me.” Another relative commented, “Yes, I do [know who the manager is], I get on quite well with them.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt confident if they raised concerns, these would be responded to by the management team.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The provider had not always had clear responsibilities, roles, systems of accountability and good governance. They had not always acted on the best information about risk, performance and outcomes.

Systems and processes to assess and monitor the service had not been fully effective. Audits had not identified 1 person’s care plan was up to date with their current health need. The systems had not ensured all staff had received training specific to people’s needs. They did not ensure all staff had their competency assessed to administer medicines.

The management team were transparent and receptive to our findings throughout the assessment and undertook action to make improvements.

The provider acknowledged the existing systems and processes needed strengthening. They gave us a detailed plan of the action they had taken to address this.

The provider understood their duty to collaborate and work in partnership, so services worked well for people. One health professional commented on how they had a positive experience of working with the staff and managers.