Fiveways

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

During the assessment we looked at the quality statements ‘Capable, compassionate and inclusive leaders’ and ‘Governance and management.’ We found the service continued to be well led. People, relatives and staff were confident in the management of the service and were comfortable to raise concerns. There were systems in place to check the quality of the service and identify shortfalls to make improvements.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager told us, “I cannot run the service on my own. I need staff to be honest with me and share any issues so they can be dealt with”. Staff told us the registered manager was “very supportive”. One staff member commented, “If I am struggling [the registered manager] will definitely help me”. The registered manager explained, “Staff are happy to be encouraged to take on other roles that they can do and are interested in”. This developed staff skills and knowledge. They told us, “We work collectively together”. Many staff had family abroad and planned trips of several weeks to see them. They told us the registered manager had a ‘holiday calendar’ and staff booked their leave in advance. They told us the management and staff team were supportive when they wished to take long holidays to visit family.

Systems were in place to share information with staff and encourage them to develop in their role and career. This had resulted in staff gaining promotions within the organisation. Systems were in operation to ensure consistent leadership of the service. The registered manager was on leave during our site visit and the deputy manager was leading the service. They understood the regulations and were able to answer our questions about how to provide good care to people. The deputy manager was supported by a quality assurance manager and a human resources team. Staff understood their roles and responsibilities and people continued to receive the support they needed.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider, registered manager and staff shared a goal to support people to be as independent as possible and to take risks. They acknowledged the potential conflict between ensuring safety and maximising independence and worked with people and their representatives to overcome these. The registered manager told us, “This is people’s home, I want to see staff supporting people in compassionate and caring ways so people feel safe in their own home”. They did this by observing staff’s practice and offering training and development opportunities. They told us, “I look at strengths and weakness in staff and encourage staff to ask for help”. Staff told us they were kept up to date at regular team meetings. They told us any changes were discussed along with people and their support needs. Staff told us they felt able to make suggestions or raise concerns and these were listened to and acted on by the management team.

There had been a delay in notifications being sent regarding Deprivation of Liberty Safeguard (DoLs) authorisations, 3 were sent after the onsite assessment for DoLs authorisations which were put in place in September 2023 and April 2024. Following our site visit the registered manager put a process in place to ensure notifications were sent without delay. The provider had employed a quality assurance manager and they had been in post for approximately 2 months. Their role was to review and improve systems and processes, such as checks and audits and learning from incidents. Plans were being put in place to improve audits of staff deployment and the content of records to ensure they were complete and respectful. Staff had completed training in confidentiality and systems were in operation to make sure staff only had access to the information they required to fulfil their role. Plans were in place to ask people if they wished their families to have access to their electronic records.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.