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• 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 Requires Improvement. This meant that the governance processes did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Managers were clear on the standards they expected, and team meeting minutes showed they set out where standards needed to improve and how they expected staff to act which included challenging poor practice where they saw it.

Staff were clear on what was expected of them and told us they would raise any concerns with management if required. Leaders set a clear vision and positive culture. Vision, Mission and Values for staff were in place and were set out in the employee staff handbook.

However, our findings at this assessment showed that standards at the service did not always meet these expectations.

A professional commented, ‘I feel the manager needs praise for doing all she can to keep her staff and residents happy. There is always a warm welcome, relaxed atmosphere and happy staff.’

Leaders were compassionate and inclusive. Leaders monitored the service and took action to improve the service though they had not identified and addressed the issues we found during this assessment. Team meetings showed clear communication between management and staff.

People consistently praised the manager. A person said, “She’ll pop her head round now and then. Seems very nice.” A relative said, “‘The leadership are good.” Another relative said, “Often had a chat with [management]. They’ve always been very helpful."

Leadership was described as supportive and visible. A staff member said, “Very supportive manager, the door is always open."

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

People felt able to speak up and raise concerns. Staff were confident raising issues with management and felt they would be acted upon. A whistleblowing policy was in place.

A staff member commented, “I would raise any issues with [the registered manager] who would definitely do something.” Another staff member said, “Management are supportive, I can easily share concerns with senior, team leader and deputy.”

Team meeting notes showed evidence of staff being given opportunity to speak up and drive improvement.

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. Policies were in place to support workforce equality. Staff raised no concerns in this area and a staff member said, “I am treated fairly at work.”

Governance processes were in place, and an audit schedule was followed to monitor the service. However, these processes had not identified or resolved the issues we found at this assessment. These included weaknesses in infection, prevention and control oversight, where audits and cleaning schedules did not identify environmental cleanliness concerns, and shortcomings in environmental safety and adaptation for people living with dementia. This meant that governance and management systems were not effective.

The CQC rating was displayed, and notifications were made to the CQC as required and the provider had a registered manager in place.

A range of policies were in place regarding information governance and the use of information as well as an emergency continuity plan.

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 service worked in partnership with others for people’s benefit. Processes were in place to ensure suitable referrals to other community partners and agencies and had been appropriately followed by staff.

Staff completed a range of audits and areas for improvement were discussed at team meetings and through staff supervisions and appraisals. However, these processes had not identified and resolved the issues we found at this assessment.

The service had been involved in a project to improve the care and management of falls. Audits noted that the number of falls had reduced in the service.