14 Thornholme Close

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. People were at the centre of this vision and there was a clear focus on achieving positive outcomes for people.

The culture of the service was person-centred. It was open, inclusive and empowering. Leaders, managers and staff understood equality, diversity and human rights, and they prioritised safe and compassionate care.

The shared direction ensured each person was at the centre of their support when decisions were made about their lives.

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.

Leaders were visible and available. They led by example, modelling inclusive behaviours, open and cooperative relationships. Duriung the 3 onsite visits we observed both the registered manager and the Nominated Individual engaging with people. They clearly knew each other well and had a good relationship.

Staff told us, “[Management] are always here. The registered manager is very humble and will do all the tasks we do” and “I would recommend this company. They treat staff well and the care is good.”

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

Staff were provided with training which outlined relevant policies and procedures and what was expected of staff working for the service. Information provided outlined the whistleblowing procedure and guided staff on what they should do if they needed to report information or concerns.

Staff told us they were confident about raising issues or concerns. They said, “Yes, the manager makes us aware there are other people we can speak to if needed” and “Yes, I feel confident to speak up if needed.”

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.

Staff told us they felt valued and that they were treated fairly.

There were a range of appropriate policies and support systems including an employee wellbeing scheme in place to support staff.

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.

As reported in the safe domain systems and processes to ensure notifications were consistently submitted to CQC required improvement during the assessment. The provider made the necessary improvements. This legal duty is now understood and we are assured the provider is now compliant.

Regular weekly and monthly audits were in place to provide oversight of key areas such as medicines and infection control. An electronic care system gave the management team live oversight of the service and regular reports were produced to analyse the performance of the service. There was a learning culture, and actions were identified for any shortfalls found.

The model of care was in line with current best practice in accordance with CQC’s guidance ‘Right Support, Right Care, Right Culture’.

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 was a valued partner in the community.The Learning Disability Autism Commissioning Team from Manchester council had requested the provider support other local services.

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 registered manager and nominated individual attended different local forums to share best practice and to access support.

The service had good relationships with the local authority commissioning team and the learning disability team who provided support to embed learning.