Head Office

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

There were a number of audit processes in place to monitor and support the overall governance of the service, but these had not always been effective in recognising shortfalls or errors due to the lack of probing questions to allow staff to recognise where improvements had been required and put appropriate actions and support in place. For example, asking if a task had been completed, but not delving into the quality or detail of the content. We found that some meetings minutes did not follow a set agenda and read more as a chat between staff than a formal meeting with outcomes and actions. The service had a stable management structure in place.

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.

Staff knew and understood the provider’s values and how they were applied in the work of their team. Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff could explain how they were working to deliver high quality care within the budgets available.

Staff told us they felt supported and worked well with each other. They knew the managers well. Staff felt morale was good. This was a diverse workforce, and they felt there were no incidents of racism, and they would be supported if they raised concerns about practices or individual behaviour.

All staff we spoke with said they felt supported and valued at the service, with both management and staff saying they felt the staff team were happy. Staff told us that at times their role could be stressful, but that they were managed and supported by colleagues and senior staff.

There were no reports of bullying or harassment at the service, and all staff we spoke to knew how to use the whistleblowing process. All staff told us that they felt they could raise concerns to management about the service without fear of retribution.

Staff felt respected, supported and valued. Staff told us they had felt well supported when incidents occurred. No member of staff raised incidents of bullying or racism during the assessment.

The Registered Manager and nominated individual had been in post for some time and knew the service extremely well.

Leaders were visible in the service and approachable for patients and staff. Leadership development opportunities were available, including opportunities for staff.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Patients and carers were involved in decision-making about changes to the service.

Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback. We saw evidence of a patient attending the senior leadership meetings and giving presentations on ideas and feedback.

Staff were able to apply to work flexibly e.g. flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. Managers put reasonable adjustments in place for staff members to help them carry out their role.

Processes in place monitored the experiences of staff. Policies, procedures and quality assurance processes sought to identify any shortfalls in the experience some staff received.

We found that team meeting minutes varied in their content and format. For example, the operations meeting minutes we were provided with lacked a clear agenda and actions/outcomes. They read more like a conversation log than a meeting with clear objectives and outcomes. However, we were also provided with meeting minutes for senior management team meetings and weekly communications meetings, and these had a clearer agenda and responsibilities for any actions.

There were a number of audit processes in place, but these had not always been effective in recognising shortfalls or errors. Audits concentrated more on checking if a task was completed than checking the quality of the task. For example, on the risk assessment audit it asks “were there any errors found” but does not ask if the patient was involved, had they signed or seen the care plan, did they agree with it and did it capture all of the risks for that patient, this was the same for the care plan audits. Another example was that a patients medication had been changed from modified release to immediate release, the medicines administration chart stated that the medicine was slow release, although the medicine given was immediate release. The medicine audits had not picked up on the prescribing error and staff dispensing the medicine had not noticed the discrepancy.

Incident logs provided on the day of our assessment were basic and did not show evidence of review or learning from incidents. However, as part of a further data request we asked for evidence of learning from incidents. We were provided with the incident investigation policy and evidence of an investigation report for one staff member. This was detailed and showed the stages of the investigation. We were also provided with a theme and trend analysis for incidents that the senior leadership team met each month to discuss.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, worked well and helped to improve the quality of care. Information governance systems included confidentiality of patient records. Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

Patients told us family members and external teams were involved in their care and treatment when they had consented to this.

The provider was open and transparent with external stakeholders such as community mental health teams and commissioners. The provider had put processes in place including, pre-discharge meetings and multi-disciplinary team meetings to ensure all relevant partners were invited to be involved in patient care.

Leaders engaged with external stakeholders – such as commissioners. Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

There were systems in operation to ensure that patients physical health checks were completed and appropriate action taken, and these were recorded within the patients’ records. Due to the nature of the service and patients living in the community, patients were encouraged to visit the local GP for physical health issues as members of the general public would, in keeping with a rehabilitative model of care.

Managers told us they were committed to continuous improvement at the service. They had ensured staff working in the service were involved in decisions about the service and worked together as a team.

Reflective practice sessions were held with staff, and debrief sessions were held when needed. Learning was shared with the staff team at regular handover and other multidisciplinary team meetings. Managers encouraged staff to reflect on what could be changed, and to problem-solve as a team. Leaders encouraged staff to speak up with ideas for improvement and innovation. Staff told us there was a sense of trust between leaders and staff.