197 Bagnall 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

We assessed 7 quality statements in the well-led key question and found areas of good practice. Our rating for the key question is good. There were clear and effective governance, management, and accountability arrangements. Staff understood their role and responsibilities. Managers accounted for the actions, behaviours, and performance of staff. There were arrangements in place to manage the confidentiality of data and records. Information was used effectively to monitor and improve the quality of care. The leadership team modelled the values of the organisation and values were shared with the wider staff team.

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 all aware of the culture and aims of the service. One staff member told us, “The culture and values of the organisation is to provide high-quality care that supports the rights of the service users to live the lives they choose or dream of as far as they are able.”

The provider shared their values and goals with the team through supervision, policy documents and regular team meetings.

Staff told us they had confidence in the management team who understood the context in which care was delivered, were knowledgeable and embodied the values of the organisation. One staff member told us, “[Manager] has extensive experience in the field and is always willing to share knowledge. I feel confident in my manager and the management team's ability to support me in my role and ensure that our team is providing the best possible care to the service users.”

The provider spoke passionately about their values and this was reflected through policy documents. The management team maintained professional qualifications to ensure they remained competent for their role.

All staff spoken with felt confident in speaking up and that their concern would be listened to and responded to. One staff member told us, “I feel confident in speaking up if I have any concerns as my manager and the entire management team are always ready to listen and take action concerning any concerns raised.”

The provider facilitated regular meetings with staff so people had the opportunity to discuss any concerns. There was a current whistleblowing policy in place to support staff to communicate concerns both internally and with external organisations.

Staff and managers gave us examples of practice that demonstrated that they valued the diversity of the team and worked towards an inclusive and fair culture. One staff member told us, “The management does all they reasonably can to support staff's health and wellbeing by making sure employees can work safely and healthily and protecting staff from discrimination, for example, making sure reasonable adjustments are made for disabled employees.”

The provider had appropriate policies in place including a flexible working policy to promote equity for staff and staff undertook appropriate training in equality and diversity.

The management team described quality assurance tasks they completed to support the delivery of good quality, sustainable care and support. The registered manager told us, “We do spot checks, audits of medication, audit daily records to make sure they are signed and dated and a monthly care plan review.”

The provider had a quality assurance policy and processes as well as policy relating to data protection. We reviewed evidence of quality assurance checks being completed and documentation reviewed.

People did not raise any concerns regarding partnership working.

The management team described how they worked in partnership with others, including other professionals, to provide a seamless service for people.

We did not receive any concerns from partners.

The provider facilitated partnership working with others to ensure people received the best care and support. However, daily records did not always effectively evidence this, for example, staff contact with the management team regarding a person’s care was not always documented which was discussed with the management team at the time of assessment.

The management and staff team all communicated the desire to learn and improve the service. The registered manager said, “We want to make a difference and whatever we have been doing there is always room for improvement. All the things identified are a positive step for us to improve our services.”

The provider had implemented processes to support continuous learning and improvement across the team. We saw feedback was sought from people and responded to, staff feedback was sought and regular discussions with staff were held to provide opportunity to share learning. The provider responded positively to feedback throughout the assessment process.