Basingstoke Centre

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 last assessment the service was in breach of the legal regulation in relation to good governance. At this assessment the service had improved sufficiently and is no longer in breach of this regulation.

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 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 told us they were happy with the company and its values. They also told us the provider had an open culture. The culture and direction of the service was driven by the registered manager who had the best interests of the people supported at the centre of all they did. The provider promoted a positive and inclusive ethos. For example, they were good at promoting staff inclusion as well as meeting the challenges of diversity. Staff told us they were clear about the provider’s key values including kindness and compassion. People and staff were listened to and communicated with. This demonstrated a pro-active approach to engagement with staff to improve the culture at the service. Staff received appropriate training in equality and diversity. Staff had a good understanding of the protected characteristics and the importance of these in practice.

The provider had a clear vision of how to sustainably grow the service without compromising safety, quality and personalised care.

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.

Staff told us leaders were open and honest, and they were able to contact them when needed. The registered manager had a nursing background and was also working towards completing their level 5 in leadership for health and social care. The registered manager used their experience to ensure good quality care was provided to people. They also led by example during the induction and shadowing process for new staff.

The registered manager knew what needed to be referred to safeguarding or notified to CQC and had made referrals as required.

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

Staff told us they felt comfortable speaking up and raising issues to the provider. The provider had a whistleblowing policy in place and staff had received training in line with this policy. The provider demonstrated an open approach in their engagement with staff and acted to address their concerns when known. Staff knew who and what to report both inside and outside of the service and felt encouraged to do so by the provider.

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. For example, the manager demonstrated how they made reasonable adjustments to staff’s working patterns and training programmes, to ensure staff were treated fairly and given appropriate support in their role. This included additional support for staff new to care or during induction and shadowing. It also included making reasonable adjustments due to maternity. Staff from an ethnic minority background told us they felt part of the team and well supported by the provider.

The provider had clear responsibilities, roles and systems of accountability to support good governance. They used these to manage and deliver good quality, sustainable care and support. However, some documentation was lacking in detail to be able to show they acted on the best information about risk, performance and outcomes.
Although the provider had improved their governance since the last inspection, improvements still needed to be complete and embedded. Some improvements were needed to the provider’s recruitment process, risk management, consent and care planning. The provider had considered these issues, and staff were knowledgeable on risks and how to support people, but the documentation did not always reflect this. However, there was no evidence of any impact to people supported and staff knowledge mitigated the risks significantly. The provider worked during the assessment to rectify these processes and put in place appropriate oversight going forward.
The provider had audits in place for medicines, daily care notes, staff files and training which were completed on their electronic system. There was also an alert system in place to prevent missed calls or medicines which was effective. The provider undertook regular reviews of care and people were happy with the quality of care provided. There was also a business continuity plan in place.

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 of partnership working with key stakeholders, including commissioners, social workers and health professionals. For example, the provider worked closely with nursing teams to keep people safe and provide appropriate ongoing care. Staff told us if they raised any concerns the office staff would follow up with professionals in a timely manner to get the support needed for people. Senior staff also told us they followed up with GPs to share updates. This helped to promote positive outcomes for people using the service. Feedback from professionals was very positive about the service.

The provider was motivated to work towards continuous learning and improvement across the organisation and local system. Although the provider was motivated to learn and improve the service for people, their overall ambition was at times limited by how they recorded and documented this and not always being aware of shortfalls to enable prompt improvement and learning. This included what we found during this assessment with recruitment, risks, consent and care plans.
However, the provider had followed up complaints appropriately with good communication to both staff and relatives. The provider was very receptive to staff suggestions for improvements for people especially if their needs changed. The provider had regular review meetings with people and relatives, to ensure the service was meeting people’s current needs. The provider had used incidents to make improvements such as updating care and support plans. There was evidence of learning and improvement with all of these.
The service had obtained a certification for quality management. The provider had undertaken mock CQC inspections to improve the quality of the service provided. The registered manager also wanted to have a culture of continuous improvement within the service. The registered manager responded quickly and appropriately to anything raised by the inspectors as part of this assessment.