St Edmunds

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 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 71 (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. People told us, “A much needed service” and “I can’t praise them enough”. The service had clear visions and values, which included focussing on what matters to people and putting them at the centre of everything. A staff member said, “There is a shared focus on providing good care for all of our clients.”

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.

Most staff were positive about the leadership of the service and felt the managers were caring. Staff told us they felt listened to. Staff members said, “The communication is very good”; “The team are brilliant” and “(My manager is) absolutely approachable and very supportive of staff if you have any kind of problem.”

However, several staff said they had not found their line manager approachable and supportive. They felt there was a lack of communication, and they didn’t know what was happening.

The provider was currently making some changes to the management structure. The registered manager told us they were planning improvements and had already started working on communication.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistleblowing policy and freedom to speak up policy, so staff knew how they could raise concerns. Staff completed freedom to speak up training. The provider had a speak up guardian; a designated individual responsible for supporting staff in raising concerns.

Most staff told us they felt able to raise concerns. However, one staff member said, “In the past, I have found the managers to be approachable and easy to talk to. However, more recently I have felt less heard when raising concerns.” We discussed this comment with the registered manager who said they would follow this up.

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.

Most staff told us they felt they were treated fairly. One staff member said, “I am treated well and fairly and I am well supported”. However, one staff member said, “In terms of being treated fairly, I would not say that I am mistreated; however, the lack of understanding when I raise concerns can make me feel undervalued.” We discussed this comment with the registered manager who said they will follow this up.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. Whilst audits were in place, there wasn’t a quality monitoring audit to enable the service to recognise shortfalls identified during this assessment.

Some improvements were required to ensure care plans and risk assessments contained detailed information for staff to follow and reflected the person’s preferences.

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.

Staff described how they contacted health and social care professionals when people’s needs changed, or they needed support. Referrals were made to health and social care professionals to ensure the best outcomes for people. Professionals told us the service worked well with them, and communication was good. One professional said, “Always willing to help and deliver the best services for our patients” and “I believe this service is a real asset to our community.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. Service developments plans were in place and on-going.The service was in the process of expanding the reablement service and were working with 3 local domiciliary care agencies.