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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

We looked at 7 quality statements under this domain: 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; and Learning, improvement and innovation. Staff demonstrated a clear understanding of the provider’s vision and values strategy. We found the provider had created an open positive culture where people, and staff were valued. There was a clear management structure that detailed roles, responsibilities and accountability. There was a Whistle Blowing and Speak Up policy and procedure in place that supported staff to report any issues or concerns. Most staff told us they were treated equally, and their well-being was considered and supported. The provider had robust systems and processes to assess, monitor and mitigate risks. There were also systems and processes in place to share learning and good practice within the service and across the organisation. The provider ensured policies reflected current best practice and legislative updates.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were positive working for the provider. They demonstrated a clear understanding of the provider’s vision and values strategy. Staff told us there was a positive staff culture within the organisation and within the service they worked. A staff member said, “There is a positive staff culture, the manager is very approachable and supportive, has an open door policy, always available, well experienced.” Another staff member said, “Our Vision and values are to show kindness, resilience and be passionate. I really enjoy my work, we support people to live a better life and integrate into society.”

The provider’s vision and values were clearly displayed within the service and known and understood by staff. The provider and registered manager had an open and positive staff culture where people, and staff were valued. People received opportunities to share their experiences about the service they received via monthly keyworker meetings. Relatives and health and social care professionals were involved in discussions and decisions. Staff were supported and enabled to share their experiences and to raise any issues or concerns via daily handover meetings, staff meetings, de-brief meetings, supervision meetings and with senior managers during visits and audits and checks.

Staff had robust checks completed on their suitability before they commenced employment. Staff were positive about the training, support and development opportunities within the organisation. A staff member said, “There's been a massive improvement, big difference in having the manager who is very proactive, has people's best interest at heart. Team leaders have good communication, care is more consistent, and there is more direction, we are better organised and accountable.”

The provider had a leadership development programme for registered managers and future managers. The provider had a clear management structure that detailed roles, responsibilities and accountability. The registered manager confirmed they were well supported by an experienced, committed, knowledgeable and skilled senior leadership team.

Staff confirmed they felt valued, respected and listened to. They were aware of the provider’s policies about how to raise any concerns and felt confident to use these. A staff member said, “I'm aware of the whistle blowing policy and feel confident to use it.”

The registered manager and provider had developed an open staff culture where staff were enabled to raise any issues or concerns. An example of this was evidenced via staff meeting records. The provider had a Whistle Blowing and Speak Up policy and procedure that supported staff to report any issues or concerns.

Staff overall were positive that they were treated equally, and their well-being was considered and supported. Some staff chose to work long shifts and others shorter, staff were supported with any cultural and religious needs. However, one staff member raised a concern that communication and understanding of staff cultural differences could be improved upon. They said, “It's a good place to work, the environment is good, the manager needs to be more flexible, communication at times could be better and understanding staff cultural differences.” Another staff member said, “The manager is wonderful, listens, open to suggestions, can be disciplined, clear about roles responsibilities and expectations. We have good communication systems, and any learning from incidents are discussed with us. Team leaders also give guidance. De-brief meetings are very helpful and improve our duty of care.”

The provider employed a diverse workforce and had an inclusive and fair culture that supported and respected the individual cultural needs of staff members. An example of this was how a staff member was supported to pray whilst on duty. The provider supported staff with flexible working arrangements; this included supporting staff to opt out of the 48 hour week. Staff also could choose their work pattern of a longer or shorter shifts.

Staff demonstrated a good understanding of their roles, responsibilities and accountability. They were confident they had access to support, information and guidance including policies and procedures to provide safe and effective care and support. Staff told us about the improvements made at the service during the last 2 years. They were confident improvements had been made to systems, processes and ways of working. A staff member said, “It’s a good place to work, I like everything about my job. Seeing people improve, live a good fulfilling life and having new opportunities. The manager has made a lot of improvements. Before people had limited opportunities to go out / integrate in the community. The manager has introduced a 11-3 and 11-5 shift 7 days a week to support people to go out and about, people are out now most days.” Another staff member said, “I really like working here, the training is really good and ongoing, better than I've had in other places. The manager is very supportive and approachable. Communication is key, so important, we use Nourish (electronic recording system), we have hand held phones and tablets to easily access information. Hand over meetings and staff meetings are regular and helpful.”

The provider had robust systems and processes to assess, monitor and mitigate risks. The provider had clear oversight and strong leadership and accountability. The provider evidenced multiple examples of their processes in place such as completing an area manager monthly audit analysis which was shared at the monthly managers meeting as a method of sharing any learning opportunities, trends, lessons learnt. There were also quarterly managers forums, a colleague recognition reward scheme and skill mapping for staff members.

People and relatives told us how staff supported them to access support and services from external health and social care professionals. Relatives were confident how staff worked in partnership with external professionals to meet their relatives individual care and support needs and to achieve positive outcomes.

Staff gave examples of how they worked with external professionals in supporting people to achieve positive outcomes. This included examples of how people had developed their independence and transferred to supported living accommodation. Other examples were given of how staff followed recommendations made by health and social care professionals. Staff told us updates to guidance, policies and new and improved ways of working were shared with them via staff meetings, handover meetings, supervision and electronic information alerts.

An external social worker provided positive feedback about how well staff and the registered manager had worked with them in meeting a person’s needs; this included good assessment and planning, and regular communication.

The registered manager and staff had a positive approach to partnership working. The registered manager kept external health and social care professionals up to date of people’s needs, incidents and well-being. External referrals were made in a timely manner when additional external support was required. The provider had systems and process of sharing learning and good practice within the service and across the organisation via different communication methods and meetings. A monthly newsletter was shared with external health and social care professionals as a method of sharing information and updates.

Staff confirmed the provider had systems and processes that supported learning and improvements. This included having de-brief meetings following an incident to consider if there were any learning and actions required to reduce recurrence. Staff confirmed communication was good and supportive in driving improvements. The registered manager and area manager told us about the opportunities, systems and processes in place that shared best practice guidance, learning and improvements and the provider’s continued commitment to further develop the service.

The provider had systems and processes to support learning and innovation. This included a commitment to co-production working with people using the service. Learning opportunities were evident internally such as de-brief meetings and analysis of incidents. Shared learning opportunities were also in place across the organisation. Communication systems in place supported the sharing of information with staff.