280-282 Wells 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 inspection we rated this key question requires improvement. At this inspection the rating has remained as requires improvement. This meant we identified some shortfalls with the governance of the service. Not all areas of improvement identified at the previous inspection had been rectified. The model of care was not always in line with current best practice guidance right support, right care, right culture. Although, leaders worked with people, their representatives and staff to build a culture that focused on enabling people to enjoy their lives, staff were not always available to people’s social needs and engage in meaningful activities. This was a continued breach in legal regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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. Leaders promoted people’s equal rights and ensured there was no workforce inequalities.

The service 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. The provider was proactive in supporting learning and development for their leaders and leaders told us they felt supported within their roles.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. All staff we spoke with told us they felt able to raise any concerns to the manager if they needed too. A staff member told us, “The manager is always there for us, to support us”.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff received appropriate training in this area and demonstrated good values in relation to equality and diversity. All staff we spoke with told us they felt they were treated fairly.

The provider did not always have effective governance systems in place to identify and drive improvements at the service. Care plan audits were completed monthly but did not always identify gaps in people’s care records. For example, where people had been supported to make decisions or where consent had been obtained. We found action had not always been taken to ensure all commissioned hours had been allocated to ensure people received staff support with their social activities and needs.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. For example, referrals were made to external health and social care professionals where this was required for people.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. The provider had not ensured learning and improvement in all areas of improvement identified at the last inspection and appropriate improvements had not always been made.