ELY DIOCESAN ASSOCIATION FOR DEAF PEOPLE (Cambridgeshire Deaf Association)

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

Prior to the assessment, there had been some instability within the staff team, however, improvements had occurred, and the culture had improved. The governance systems had been reviewed, and an external quality consultant was working with the service to further strengthen oversight. The registered manager was aware of their legal responsibilities and was open and transparent with us, throughout the assessment.

This service scored 82 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager was transparent with us regarding some difficulties faced prior to the assessment which had caused some changes within the staff team. Staff told us they had experienced a difficult period with staff changes, and this had impacted upon the culture of the service. However, during our assessment we found actions had been taken in respect of this, and where difficulties had been experienced, the registered manager was proactive to ensure people were safe, and communication took place with relevant agencies. Furthermore, the registered manager assessed the staffing needs of the service to ensure the right people were in the right roles, and we found positive change had taken place which ensured positive outcomes were experienced.

The registered manager and senior staff team ensured effective communication opportunities were available for staff. This included being visible in the office, being available out of hours, and being contactable using specific communication systems which met the needs of staff. We found responsive measures had taken place to encourage an open and honest culture.

Staff told us there had been some issues with culture and communication at the service. The registered manager had reviewed the service to ensure the right senior team were in post, and staff told us improvements had been made. Furthermore, the registered manager had plans which recognised succession planning, and talent management within the staff team. The registered manager was open and transparent throughout the assessment process, and acted when they received feedback from people, staff and other stakeholders.

The management team were compassionate and capable to undertake their roles. Processes in place allowed for monitoring and management of the service, and the registered manager took prompt action to ensure reviews were completed when required. The management team were passionate about the service, and the support provided by staff, and spoke very proudly of the outcomes experienced by people.

We found there was an open and honest culture at the service and there were opportunities for staff to speak up. We had received anonymous concerns prior to our assessment, regarding the culture at the service, but we found action had been taken by the registered manager following changes within the staff team. Staff told us they had noticed positive changes had taken place and communication had improved.

Policies in place supported staff to raise concerns, both internally and externally. Staff meetings and staff supervisions were held regularly and provided opportunities for staff to share any concerns. Staff were able to access independent advocacy services, should they be required. The registered manager had reviewed staffing deployment and had clear oversight of staff allocations to ensure staff had opportunities to meet with them. There were differing ways for staff to contact the management team, dependent upon their communication needs.

Staff told us prior to the assessment their experience of equality, diversity and inclusion had decreased. For example, 1 staff member told us, “[I] feel like we have not been treated fairly.” However, since new staff had joined the service, staff told us this had improved, and 1 staff member told us, “I feel [manager] does support me” and “With [manager] I do feel listened to.” The registered manager should ensure they continually seek staff experiences to enable them to be recognised and acted upon. The registered manager, and management team, spoke highly of the staff team, and there were different employment recognition systems and programmes in place which celebrated achievements.

Staff had completed equality, diversity and inclusion training and had continuous access to the services’ policies and procedures. Staff were supported to progress within their career, and suitable systems and training was sourced to meet the needs of the staff team and to allow progression.

The staff and management team provided a safe service, and we found it was well led. The registered manager was aware of their regulatory requirements and responsibilities under the duty of candour. Duty of candour is a professional responsibility to be honest with people when things go wrong. The registered manager was open and honest with us, throughout the assessment process. Staff were clear about their roles and responsibilities and knew what to do if they needed support or to raise concerns.

Governance systems at the service were mostly effective, however, we did find some examples where thorough reviews for risk were not prompted by the providers policies and procedures. This included some people’s health risks not being fully identified in care plans, and staff competency checks not being up to date for medicines administration, and the use of manual handling equipment. We pointed these out to the registered manager and these areas were reviewed without delay, action was taken, and systems were put into place to help mitigate future occurrences. However, it is important the providers quality assurance systems are monitored to ensure they identify any future shortfalls. The registered manager had introduced additional quality checks at the service, which were being undertaken by an external quality contractor.

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.