Include 'In' Autism

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 requires improvement. The rating for this key question 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 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. The provider’s organisational values were in alignment with the CQC’s ‘right support, right care, right culture’ guidance. The provider and registered manager had a strong commitment to ensure people received the best service. People were at the heart of the service. The ethos of person-centred support and enablement was embedded within the service and the belief that people had a right to live a fulfilled life and be supported to achieve their potential. Staff were proud of their caring approach towards people and believed strongly in the values of the service. Staff members’ comments included, “Overall the service promotes dignity, safety and person-centred care, and staff are encouraged to deliver high-quality support”, “I love my job and feel part of a supportive caring team, who put services users first”, “The role is very rewarding, being part of an individual’s journey and being able to help them achieve the best of themselves” and “Work is very rewarding.”

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. The registered manager demonstrated they had the skills and knowledge to manage the service effectively. The provider and registered manager were studying for qualifications at level 6 in positive behaviour and support to give them more insight and expertise into some specialist needs. Relatives and staff said the registered manager was approachable. They described them as, “Friendly, accessible and pro-active in their management style.” A staff member commented, “The manager is approachable and supportive.” Another staff member told us, “I feel the service is supportive, person-centred, and committed to continuous improvement.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Processes were in place for staff and people to speak up. The provider had a clear whistle blowing policy. Staff could raise concerns and the information about how to do this was available in the staff handbook. Staff meetings took place. Staff told us they felt valued and supported by the management team. They were encouraged to voice their opinions, ideas and suggestions. A staff member commented, “I have never had any problem going to the manager to highlight issues or give suggestions, they are very approachable.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff had received equality and diversity training. Staff told us they were treated equally and did not experience any discrimination. They told us they felt valued and respected in their roles. They said they felt supported by the management, some said they were well-supported personally when needed.

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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate. There was oversight from the provider to review the quality and safety of the service in line with regulatory requirements, with regular quality checks carried out.

Staff at the service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. Staff worked alongside other professionals to ensure appropriate support was provided.

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. Staff and leaders had a good understanding of how to make improvements happen. Leaders encouraged staff to speak up with ideas for improvement. Processes to ensure that learning happens when things go wrong, and from examples of good practice were well-established. There was evidence of changes that had been made to the service to make improvements and to address checks and audits outcomes and in response to people and staff feedback.