Mitcham

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.

This is the first assessment for this newly registered service. This key question has been rated 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 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 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.

The provider’s policies and procedures reflected best practice in care and support and the importance of valuing people as individuals. The feedback we received from staff showed they had a shared understanding of the service’s values, policies and procedures, and their roles in ensuring people’s individual choices and rights were respected. Staff were provided with opportunities to discuss best care practice and regulatory requirements during regular supervisions and team meetings.

The provider had inclusive leaders 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.

People’s relatives and staff spoke positively about the management of the service. They told us the registered manager was approachable, professional and accessible at any time. Staff told us they appreciated the support they received from the registered manager. The registered manager had significant experience and knowledge of the social care sector. They understood the importance of honesty and transparency and their duty of candour responsibilities.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People’s relatives and staff told us they could raise concerns at any time. They told us they were confident their views and concerns would be listened to and acted upon. The provider had a whistleblowing policy and staff were aware of this.

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.

Staff had received equality and diversity training. They felt they were treated fairly and equally. The registered manager told us they would always seek to make reasonable adjustments for staff who required flexible working patterns or equipment to enable them to carry out their roles.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had systems in place to ensure people received good quality care. Regular quality assurance monitoring and audits had taken place, and issues identified had been addressed promptly. People and staff had been asked for their views of the service and their feedback was positive. The registered manager and staff understood their responsibilities to report any concerns, including to Local Authorities and the CQC where appropriate.

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.

People’s care records showed the service had engaged with relevant health and social care providers to achieve the best outcomes for people.

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.

The registered manager spoke of the importance of continuous improvement and development of the service. Staff told us they were provided with opportunities to contribute ideas and suggestions in relation to the way the service was delivered.