The Office

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 requires improvement. 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. At our previous inspection we identified a breach of regulations in relation to the management of the service. Improvements were found at this inspection, and the provider was no longer in breach of the regulations.

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.

Staff meetings were now being held along with staff supervisions and appraisals. This meant the registered manager was able to share and demonstrate organisational values with the team. Since the previous inspection the registered manager had taken more of a lead role and staff were encouraged to go to them with any queries.

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.

The registered manager had developed organisational care plans and was no longer reliant on information from other agencies when planning care. Risk assessments were completed when any risks were identified and these covered medical needs as well as needs associated with people’s emotional well-being.

At our previous inspection we identified a risk of a closed culture developing. Actions had been taken to mitigate this. For example, an external professional told us the registered manager had been open to developing the service and had asked for advice when needed.

The registered manager had notified CQC of any untoward events as required.

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

Since our last inspection a safeguarding role had been introduced. This was covered by a member of staff unrelated to leaders at the service providing an alternative route for staff to raise safeguarding concerns.

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 preferences were known to managers and respected. Staff told us they were treated fairly and without discrimination.

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.

Since our previous inspection improvements had been made to the service. The registered manager had worked with the Local Authority quality assurance team to identify areas for improvement and make the necessary changes. Records were now well organised and regularly reviewed and updated. Rotas clearly outlined when people would receive their commissioned hours.

The registered manager was supported by an operations manager and project manager. Each manager had clear roles and responsibilities and provided a support network for the registered manager.

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.

There was evidence the service worked with other agencies and shared information to improve people’s experiences. Managers had collaborated with health care professionals to safeguard people’s rights. One healthcare professional told us, “Overall, my communication with management has generally been good, and they have been approachable.”

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.

There were now systems to monitor the service and identify areas for improvement. Managers reviewed care plans and risk assessments. Incidents and accidents were recorded and any themes identified. The registered manager was open to suggestions and actively sought advice from external agencies.