Head Office Also known as Swindon

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.

This is the first assessment for this registered service. This key question has been rated requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created 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.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider strived to deliver care that focussed on belief, growth, tenacity, aspirations, motivation and empathy. However, children and young people requiring support with their anxiety related behaviour did not always receive proportionate care that promoted their human rights and safety.

However, staff were aware of the provider’s values, and one staff member was able to provide examples of how they worked to these. The staff member commented, “We believe in what [people] can achieve, motivating them daily to work towards goals and individual aspirations.” We saw evidence of staff working in line with these values, such as encouraging people to achieve their goals.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

Leaders were not always aware of best practice guidelines and legislation in relation to the Mental Capacity Act, and Right Support, Right Care, Right Culture and good practice guidance and interventions for people with learning disabilities whose behaviour challenges.

Therefore, we identified shortfalls in relation to some practices.

However, we received positive feedback from relatives, staff and professionals about the manager. Comments included, “They are extremely professional and clearly work tirelessly for the young people in their service” and “[Manager] has an abundance of knowledge and experience, and she is always keen to pass this on to anyone. She leads by example and sets standards very high and rightly so. She does however nurture, train and guide staff to reach those standards through her positive leadership and management skills.”

One professional commented, “I have found [manager] to be thoughtful and reflective about how best to utilise our guidance or recommendations in their work. She is responsive to requests for information, such as recording logs or behavioural reports and open to advice or suggestions on the basis of our findings. I have found her to be proactive at raising safeguarding concerns and thoughtful in the way that systems can work collaboratively with families and young people to address these.”

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

All staff told us they were confident raising concerns to the manager. Comments included, “I am aware of the term and feel confident and comfortable when doing so with [manager], she listens and reacts in the appropriate manner every time” and “I feel able to speak if I have any concerns and during supervisions, I am always given an extra opportunity to express any concerns I may have”. The manager told us, “Staff do speak up about things, we also have an email address which staff can use to raise concerns. The service is well signposted in relation to staff being able to raise 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 did not raise any concerns about workforce equality, diversity and inclusion. The manager told us, “With our rota system staff can apply for the shifts they want. During the recruitment process, staff have to complete equality and diversity forms. We always ask if staff are feeling supported and we have regular supervisions. I ensure everyone feels included and supported.” Staff gave us examples of how the manager had been flexible with their working hours to promote workforce equality, diversity and inclusion.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not have effective governance systems in place to ensure safe, person-centred and sustainable care. Systems and processes to assess, monitor and improve the quality and safety of the service were not effective.

Prior to our inspection the provider had not identified the shortfalls we found through their own monitoring systems. Prompt action was therefore not taken to prevent these shortfalls from impacting on people’s care. For example, prior to our inspection the provider had not identified systems and processes for ensuring incidents were dealt with safely and proportionally, were not effective. They had not identified that not all people had positive behaviour support plans in place and did not ensure staff had the required skills to complete behaviour support plans in accordance with national best practice. They had failed to identify care was not always delivered in the least restrictive way as they had not always provided staff with clear guidance to support people effectively in times of distress. Additionally, the provider’s supervision template did not include space to discuss safeguarding in sufficient detail, in line with best practice.

The provider did not identify staff did not consistently follow their policies. For example, although the provider’s policy stated restraint was rarely used, records showed that restraint was regularly used in practice. This demonstrated a significant shortfall between governance frameworks and day-to-day care delivery, placing children and young people at risk of inappropriate and potentially harmful interventions.

Governance systems had not ensured all risks to children and young people were identified, assessed or effectively managed. Medicine management was not always safe. Oversight systems did not ensure concerns, patterns or risks were recognised or acted upon in a timely way, with shortfalls in root cause analysis found during assessment. This meant leaders did not have accurate information to ensure people were safe or that care was being delivered in line with expected standards.

The impact of lacking governance systems meant young people received care which was potentially unsafe and unlawful. Following our assessment, the manager told us they had successfully recruited a deputy manager to build a stronger management team. The manager also told us they had reviewed their policies and processes and reviewed their governance procedures.

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.

We received positive feedback from professionals working with the service. Comments included “Bespoke have been thoughtful about allocation of workers where it is possible to do this. For example, they asked for additional time to source the right workers for a particularly complex situation, rather than rushing to put in place an emergency package that may not have met the needs of the family”. The same professional commented, “The team are responsive to requests to meet and attend prearranged multiagency meetings, offering valuable insight into the family and young person’s needs.”

Relatives told us the service worked collaboratively with them to improve the care and support for their family member.

Although the service aimed to promote ongoing learning and improvement, we identified several concerns during the inspection, which are highlighted throughout this report. The provider was motivated to learn and improve, but the lack of effective risk and quality monitoring systems meant all areas for learning and improvement were not always identified. As a result, leaders were not always aware of shortfalls and could not consistently act promptly to drive improvement.

We found similar concerns at our last inspection. This meant the service had not effectively learnt and made sustainable improvements. However, the manager gave examples of how they had recently made improvements to the service, such as making their online care planning and recording application more user friendly.