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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

The registered manager understood what their roles and responsibilities were. They knew they had to inform CQC of any notifiable incidents in line with the current regulations. The management team had systems to monitor and improve quality of the service provided. People, relatives, staff and other professionals were encouraged to help improve the service provided to people. There were regular audits and checks were undertaken to ensure the service was run well.

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.

The manager told us that they worked hard to make sure that the service had a positive culture. For example, the registered manager said, “It's important to engage and work with people and their family and ask for people’s views. Knowledge sharing is the key for creating a positive space for lessons learnt for improving the service that employees are collectively experiencing. It’s about creating a comfortable environment for everyone to share and feel they can be open.”

The registered manager told us about giving safe care and support, “It is also about our values and behaviours within our organisation that inspire understanding and trust with the people and families we support.” Staff told us that they felt that their manager fed positive energy and inspired them to be able to give the best care and support possible to people. A member of staff told us that they truly believed this service gave people good care and if they were able to, they would like their family member to move to the service, as they were looking for a new home for their relative who needed care and support.

Staff told us that they felt that the management at the service listened to everyone's ideas and concerns. A member of staff told us, “We can speak to the manager at any time, and we don’t need to wait until we have supervision. I feel that I’m valued and listened to and I'm able to give my opinions, as well as raising any concerns.”

The registered manager explained the importance of being open and supportive to staff and people they supported. The registered manager said, “Age should not restrict a staff member in developing their skills and knowledge. It's about developing staff's skill and their knowledge. This practice also includes supporting people to develop their social and learning skills and is about adapting the way we support people to understand and carry out a task step-by-step. The key is about including people in the process as much as possible.”

The registered manager was aware of when the CQC should be informed of events and incidents that happen within the service and the responsibilities of being a registered manager. They kept us up to date with any changes that happened at the service and provided us with information promptly when we had requested them. There were regular meetings held for staff to share their views and experiences and for the registered manager to cascade information about things happening in the service. The registered manager told us that a good service is about implementation of systems that work, that staff can use, as well as having up-to-date policies in place. The manager also told us they were about to implement a new online digital system that would help to analyse their audits. They told us it is important how you implement the auditing processes so actions identified can help to improve the service.

Effective systems were in place to quality assure the services provided, manage risks and drive improvement. There were several systems in place to help ensure that the service to continue to improve and develop. This was done by completing audits and spot checks were carried out by the management team. There were action plans in place to help with improvement and long-term and short-term plans. The management team also held staff talk about areas that had been identified to help develop the service and learning from incidents and accidents as well as complaints and safeguarding.

We saw evidence that the service worked in partnership with different agencies, organisations, to improve outcomes for people. For example, people were supported to health appointments. One relative told us, “The home is very good at identifying and acting on health concerns, staff will also contact me and give me an update on the outcome of the appointment.” A person using the service told us that they are supported to access the community and they have been able to join new social clubs and meet new friends.

Staff told us that they work with different types of agencies such as social workers, health professionals. A staff explained, “It's very important to build these relationships up as the partnership working helps to ensure that care and support meets the individual person's needs and I have learnt a lot from other people which helped me develop my skills.”

We saw evidence of positive partnership working in documentation of care review meetings, health review meetings and of staff contacting medical professionals for advice if needed. The outcomes were recorded in people's daily notes and care plans were updated accordingly.

The manager explained the importance of learning and improving their service and said, “When reviewing accidents and incidents and completing and analysing audits, we always feedback to staff. We ask them for their ideas and how we can improve the areas that have been identified. By doing this, it brings the team together, helps problem solving and [encourages] involvement from others. It also feels [there is] a positive culture within the service. In my view it’s not about the issue that has been identified, it is about the actions we take and how we learn from it.”

We saw evidence that regular care reviews were taking place, and this included reviewing people's risk assessments. Records showed care documents were reviewed and updated from feedback suggested by relatives. The management of the service carried out regular audits to help identify any gaps or areas that needed improving.