Voyage (DCA) Hampshire

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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 good. At this assessment, the rating has remained 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 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 service 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.

Processes were in place to promote equality and diversity for people and the staff team.

The registered manager told us, “Our ethos is about empowering individuals, working together, being honest, thriving to be outstanding and supportive. We foster a culture of learning and transparency, and we have an open door policy. We work collaboratively with staff, we are open and honest, we seek views and work with them. Our values are embedded within staff inductions. Our values are included in our recruitment advert. We ask value based questions during the interview process. We ask candidates to give us an example of when they have been open and honest.”

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

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

For 1 of the supported living households there were concerns around continuity of leadership as there had been several managers in the past few years. The new management team in post, told us they were aware of issues and priorities within the service and were working towards improvements and changes to systems and processes. This included ensuring people lived a fulfilled life. We received mixed feedback from relatives. Some relatives told us about the concerns they had relating to the high turnover of managers and the inconsistencies this had caused.

A person told us, “Within the last couple of months, [Service name] has been in the best place it has been in ages. My friends and family have noticed I am so much lighter. It’s down to the new manager and deputy manager and my involvement in the interview process and making sure we get the right staff.”

People were enabled to live good, ordinary lives as part of their communities.

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always report safety events to external stakeholders.

Relatives told us they had difficulty in contacting the provider when they had safety related concerns. They also told us the provider was not always responsive and did not always feedback any action taken relating to their concerns.

Lessons were learnt to identify and embed good practice. Staff knew what incidents to report and how to report them. The manager shared learning with staff through staff communication channels and team meetings. We saw evidence of change as a result of incidents which had occurred.

The registered manager told us they received safety alerts from the government, local authority and CQC which informed them of upcoming risks along with themes and trends to ensure the provider could take appropriate action to mitigate these risks.

The service 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 felt supported to give feedback and were treated equally, free from bullying or harassment.

People with protected characteristics felt supported. A staff member told us, “I like the provider very much. I am a migrant worker and there is a level playing field. The company 100% give’s everyone equal opportunities to grow and improve. I am completing my NVQ 3. The company has an open door policy, and the managers investigate concerns fairly.”

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.

Staff understood their roles and responsibilities. Staff and the management team understood the importance of reporting any changes to people’s wellbeing. They kept detailed records of the support people had received. There were effective governance processes in place to monitor and improve the service. Where audits identified shortfalls, actions were implemented and reviewed. The provider monitored improvements, and some time was needed for newly introduced improvements to become part of everyday practice.

People mostly received care and support in accordance with the principles of ‘Right care, right support, right culture’ guidance. People whose records we reviewed had recently reviewed support plans, risk assessments and PBS plan’s in place. People had access to a staff allocation sheet so they could see which staff members would be supporting them. Where people who requested for a different staff member to support them this was facilitated by the provider wherever practicably possible.

People were supported to attend regular meetings with their landlord so any tenancy concerns could be managed in a timely manner.

The manager was able to confidently tell us how they ensured safe record keeping by following the principles of General Data Protection Regulation (GDPR).

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

We sought feedback from some professional’s. One professional told us, they did not think the provider worked in partnership with them to ensure good outcomes. They shared an example of this. They also told us, they thought the current manager seemed to be doing what they could to improve the service. The registered manager shared with us several examples of where they had worked collaboratively with people and the professionals involved in their care, focusing on enabling people to develop new skills and enjoy their lives.

The registered manager also told us, “We have a CQC nominated team who look at themes and trends and lessons learnt from recent inspections and cascade what we can improve on.”

The service strived to focus on continuous learning and improvement across the organisation and local system. Staff and leaders were working to establish a consistent approach to improvement including monitoring progress and outcomes.

The PBS practitioner gave us several examples of how people were supported creatively to achieve positive outcomes, for example, for 1 person they told us, “We have an extensive communication process. There are 2 communication folders with pictures. A visual planner for the week which is updated every week. A visual staff allocation. A visual countdown timer which can go up to an hour. The person has social stories software as these work for them. We also train the staff on how to make an effective social story for the person.” This supported a culture that focused on enabling people to enjoy a full life.

The provider was responsive to our findings and acted immediately on key areas of improvement. They shared with us a detailed action plan of the actions they had taken and would be taking following our visit.