Smitham Downs Road

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.

The provider was no longer in breach of regulation relating to good governance.

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.

The provider’s values were in line with their vision ensuring people received personalised care that met their needs and celebrated diversity and inclusion. The governance system was structured around the provider’s values and underpinned their annual impact report.

The management team at the service needed stabilising to ensure consistent leadership and oversight of the service. In the year preceding our assessment there had been several changes of manager at the service. The day of our site visit was the new permanent manager’s first day. Prior to this the team was being supported by a peripatetic manager. The deputy manager’s position had recently been recruited to, but they had not yet started in post. The provider was also recruiting to two practice lead roles.

Staff felt supported in their roles, but staff and relatives felt the service would benefit from some consistent leadership.

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

Staff felt comfortable speaking up and raising any concerns they had. They told us they felt listened to and felt able to speak openly. A whistleblowing policy was in place and speak up procedures were available for staff.

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 were well supported and there was flexibility to meet staff’s individual needs. Policies and procedures were in place to support equality and diversity, ensure staff worked in a place that was free from discrimination, support flexible working and lone working.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Improvements had been made to the governance system and staff were adhering to the provider’s requirements and regular audits to review the quality and safety of service provision. Centralised systems were used to record and review key service data, to look for themes and trends. The provider’s quality and governance team ensured appropriate action was taken to learn from any events or incidents that occurred, this included learning across their services. The provider’s quality team also undertook their own audits and reviews of the service in a mock ‘CQC’ style. If the service was rated below good, an intensive programme of support was available to improve practices.

The staff worked in partnership with other health and social care professionals involved in people’s care. There was regular joint working and open communication to support continuity of care. Staff welcomed feedback from partner agencies and took on board advice and guidance provided.

Staff also asked people and their relatives for feedback about the service through the completion of annual surveys. However, the relatives we spoke with felt they were not involved in the service and felt communication between staff and families could be improved so that they felt more informed. The manager told us they had introduced themselves to the relatives and offered regular update calls. They also had plans to introduce a regular newsletter to further improve communication and partnership working with families.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The management team were aware of the improvements required at the service and were in the process of strengthening the management and leadership of the service. There was also a full refurbishment plan in place to make the necessary environmental improvements. A plan was in place to track progress of the improvements required and to ensure continuous development of the service.