Azalea House

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

As part of this assessment, we looked at 7 quality statements for the key question of well-led. These were ‘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 and learning, improvement and innovation. Staff had an exceptional understanding of equality, diversity, and human rights, and they provided safe, high-quality, compassionate care. The registered manager was very experienced and had an excellent understanding of the key principles and focus of the service, based on the organisation’s values. The management and staff team demonstrated an open honest and transparent culture, and all staff were confident their voices would be heard. There was a strong organisational commitment and effective action to ensure there was equality and inclusion across the workforce. There were robust governance arrangements and staff understood their role and responsibilities. The management and staff teams worked in partnership with key organisations to support high quality care. There were processes in place to ensure that learning happened when things went wrong, and best practice guidance was sought and shared.

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

The staff training, supervision and support systems fully enabled staff to progress within their roles, and to achieve their full potential. There was a shared commitment to all staff working cohesively with 1 shared goal. Staff had an excellent understanding of the provider’s values and the vision of the organisation. One staff member told us, “The manager is such a positive force and excellent role model. She leads by example and brings us together as a team, so we all work towards the same goals.” Written comments from staff included, “We admire your ability to lead and bring the best out in the team.” And “Your dedication to our success never goes unnoticed.” The registered manager told us, “I have the autonomy to develop and evolve the project in the provision of targeted person centred care that enables individuals to live their lives as they choose whilst minimising risk and harm. We look at trauma and triggers and how they can be identified, and support implemented into the individual's life, so they have a fulfilled life where they feel safe secure and happy.”

Staff were required to complete an equal opportunity form when they first commenced their employment. This was based on equality and diversity whilst highlighting people’s own protected characteristics and cultural backgrounds. There were regular updates for staff through staff through meetings, emails, newsletters, and intranet postings about the organisation’s vision, values, and strategic goals. Staff completed mandatory training sessions to understand the vision, values, and strategic goals, and how their roles contribute to achieving them. The vision, values, and strategic goals were prominently displayed in the workplace. There were regular planning meetings involving staff, people who used the service, and external partners to gather input and feedback. Workshops took place that brought together people using the service, staff and partners to co-develop and refine the providers strategy and future plans.

Staff said the registered manager was an exceptionally kind, caring and compassionate person. Written comments from staff included, “You are the best manager. We know it’s not easy, but you make it look easy. A manager who never leaves our side and is worth looking up to.” And “You make working hard easy. Thank you for being the great manager and kind person that you are. It’s such a pleasure to work with you.” Promoting independence, health promotion and safe risk taking were fundamental aspects of the ethos of care and support at all levels. The feedback, culture, and attitude of all the staff was that nothing was too much trouble; and everyone involved was willing to go above and beyond expectations to ensure people could have enriched and fulfilled lives. We received feedback from a healthcare professional who commented, “I found the manager, staff and service users all extremely positive about the service and the manager was very responsive on the day of the assessment.”

The registered manager had embedded a rights-respecting culture at the service. The registered manager had the experience, capability and integrity to ensure the smooth running of the service and ensured that risks were well managed. The registered manager was a substance misuse practitioner. They were able to offer specialised prevention support and aid wellbeing and stabilisation through their experience and knowledge. The registered manager shared their knowledge with the staff team who applied the same therapy models to minimise negative impact. Risk management plans were proportionate and centred around the needs of the person. They were regularly reviewed with other health care professionals, and they took note of equality and human rights legislation. Records demonstrated that strategies were in place to make sure that risks were known, anticipated, identified, and managed. The provider was committed to continually motivating the staff team and recognising their dedication to their role. For example, their was an employee of the month scheme.

All staff we spoke with told us they were fully encouraged to speak up and this was always discussed in team meetings. One member of staff said, “The manager talks to us all the time and always encourages us to speak up. As a whole team I don’t think we would have any worries about speaking up because the manager is open, passionate about keeping people safe and very compassionate.” A second member of staff told us, "Our manager drums it into us that we must speak up if we have concerns. They are so open and kind we would not hesitate to speak with them if we had any worries. If we didn't we would be letting our residents down, our manager down and ourselves down."

Freedom to speak up was highlighted in the staff handbook where staff had access to a whistleblowing policy and phone numbers of those to call if they wanted to share concerns. Surveys were sent out to people and staff so that they could share their views on the organisation or raise any concerns. Records showed that during staff meetings, supervisions and appraisals staff were encouraged to speak up and be heard. Any information was acted on and respected. The provider organised workshops where staff and people using the service discussed the importance of speaking up.

The registered manager said that having staff with the right values and skills was essential and people using the service were involved in the recruitment process. This was to ensure potential staff matched the values that were at the heart of the service. There was an open and transparent culture where staff had opportunities to share information. This culture encouraged excellent communication and learning, which achieved positive outcomes for people. One staff member told us, "We are always encouraged to speak up with our views and opinions. Our manager is a great listener, and our voices and opinions are respected and acted on to make things better for the people we support." The registered manager showed us a film of where staff get rewarded and recognised for their dedication and hard work. There is an awards ceremony and staff have a meal on the night with entertainment, team building fun and different speakers. Staff’s religious needs and cultural needs were supported and respected. For example, shifts were arranged to enable to staff to attend church and staff were also empowered and enabled to have prayer time whilst on shift. Staff were enabled to have 3 - 4 weeks leave at a time due to cultural needs and all the team support this by covering the shifts.

Staff completed surveys so they could give their views and ideas. We saw from the minutes of the staff meetings they were fully informed of what was happening in the service and any incidents were shared for lessons learnt. There was a strong organisational commitment and effective action to ensure there was equality and inclusion across the workforce. For example, leaders were provided with training in compassionate leadership, active listening, and effective communication to ensure they could support staff with their diverse needs. The provider encouraged an open-door policy where staff could feel comfortable sharing concerns and suggestions with leaders. There were recognition programs that celebrated positive behaviours, compassionate care, and teamwork. Feedback from staff was listened to and acted on. For example, the times of shifts were changed because staff wanted longer shifts to be able to provide better consistency of support to people. The registered manager had supported training that was requested and had changed lead responsibility where someone struggled with the audit processes.

The registered manager demonstrated they were highly committed to improving the service they provided and had introduced a number of initiatives to help make improvements. These included introducing champions within the care team for a variety of relevant subjects such medication, safeguarding and fire safety. Staff felt empowered to lead within their own areas of the service and initiate new ways of working. For example, 1 staff member told us how they had been supporting people with artwork in their care plans. Staff described supervision and appraisal as regular and supportive, with staff praising the high level of support they received from their line managers. Staff were motivated and proud of the service. All the staff we spoke with said they had great job satisfaction and were supported to develop their skills, giving them lead roles and empowering them to drive improvements and new initiatives.

The provider had successfully embedded a very robust auditing system. This included regular internal audits in areas such as accidents and incidents, risk management plans, staff training, staff supervision, reviews of people's goals and recruitment records. Best practice was shared throughout the team, identifying what had worked well for each person, or what had not worked well. The dynamic nature of the care provided, required the registered manager to have excellent oversight of the service. They continuously monitored the service to drive continuous improvement. The provider invested in the learning and development of its staff, which benefitted people through the maintenance of a stable, motivated and highly skilled staff team. The registered manager and staff team were clear about their roles, and there was a strong framework to monitor quality performance, risks and regulatory requirements.

We saw numerous examples of innovative collaborations between the service and other agencies. For example, we saw that Azalea House worked with other services supporting people with addictions and a referral would be made to Pathways which provided drug and alcohol advice, treatment and support to adults whose lives were affected by addiction. There was a good working relationship with the police who supported the service when people were at risk or missing. This had a positive impact on people who had benefitted from this collaborative way of working. For example. GPs had reviewed medication and reduced medication that had a negative impact on people in way of side effects. The Community Mental Health Team (CMHT) had changed medication for 1 person to reduce side effects and improve their wellbeing.

The registered manager told us, "We assess people’s needs, their diagnosis and ascertain what support is required to have a positive impact on the lives of people using the service. If it’s a mental health need, we will refer to the Community Mental Health Team (CMHT) or If it’s health, for example we may see a diabetic change, we will then work with the diabetic nurse to gain the correct treatment plan. The registered manager said, "Social workers have supported people where they need funding for 1:1 hours. Benefit provision has been contacted and people have been supported to claim money they were entitled to."

Professionals involved in people's care at Azalea House told us the service worked collaboratively with them to achieve positive outcomes for people.

The service was transparent, collaborative, and worked in partnership with key organisations to support care provision, service development and joined-up care. The service had worked closely with new community initiatives and would work in partnership with social workers, care coordinators, people's GP, consultants, the police and local groups. They had worked with advocates and solicitors in the past and also with the LA and council where needed in relation to housing. The service has also worked with the criminal justice system which had ensured people received the right support in the community.

There were robust processes in place to ensure that learning happened when things went wrong, and best practice guidance was sought and shared. A staff member told us, “The manager shares incidents with us at meetings and these are taken very seriously. We have de-briefs daily where we discuss incidents or accidents as well. We learn lessons when things don’t work well and try to make improvements.” Another staff member commented, “Lessons learned is always discussed and is a very important part of what we do. Things don’t always go as planned and we have to change, learn and improve.”

The provider was extremely committed to improving the service they provided and had introduced a number of initiatives to help make improvements. These included introducing champions within the care team for a variety of relevant subjects to ensure staff were kept up to date and could gain support and advice when needed. There was a focus and importance placed on ensuring staff had the skills to do their jobs well with opportunities for continued learning and development linked to the needs of people. The provider embraced success and promoted good practice. For example, if there was a gap in staff knowledge the registered manager would organise training and workshops to meet that need. This ensured that people’s treatment and support achieved good outcomes and was based on best available evidence. Supervisions and team meetings were used to openly discuss training needs and further training would be accessed if staff felt they needed it, which in turn better supported safe and effective practice. The registered manager kept excellent oversight of lessons learned and there was a log that detailed incidents, what had worked negatively and worked had worked positively so that appropriate changes could be made and lessons learned.