Medica Operational HQ - Havelock

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• 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

The service had clear responsibilities, roles, systems of accountability and good governance and used these to manage and deliver good quality, sustainable care, treatment and support. Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care.

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.

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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 service had a clear governance structure with various committees. Subcommittee meetings fed into the clinical governance meetings to ensure information was shared across all services and that staff were fully informed of any risks and safety concerns. We reviewed the governance minutes which were attended by the senior leadership team. This showed risk had been reviewed and escalated appropriately to their departments. The Clinical Governance Committee (CGC) met fortnightly and provided oversight of reporting audit and discrepancy. It also provided oversight for clinical investigation and complaints and monitored the actions which arose. Medica had a response to reporter concerns process with an escalation pathway which was overseen by the Clinical Governance Committee and in turn the Medical Advisory Board. There was high level reporting to the Company Board with oversight from the PLC Board Clinical Governance and Quality subcommittee. The Medical Advisory Board (MAB) had oversight of clinical governance and met quarterly. The MAB reviewed the clinical appraisal and revalidation process, the clinical audit committee (CAC) and clinical appraisal committee outputs. Medical policies were reviewed and signed off at the MAB. The MAB reported to the Company Board through the Medical Director who was accountable to the Board. The CAC reported to the company board via the Medical Advisory Board. The CAC worked closely with the Clinical Governance Committee with a minimum of two members attending both meetings. The service had a risk management policy which was in date and set out the governance structure to ensure risks were managed and escalated as appropriate. We reviewed the recent corporate risk dashboard which showed that active risks for the medical risk register went down to 26 from 44 in quarter 3. Likewise, the active risks for the corporate group had also gone down from 2 to 0 in the same quarter.

The service worked with a variety of clinicians based both in the UK and overseas and had a customer engagement policy which outlined the principles by which the service managed and facilitated customer engagement for the duration of a contract across Radiology and Pathology services. Service users had access to the portal where they could notify the service of reporting discrepancies. The service had a Medica Insight Client User guide which was in date and provided guidance on the use of the portal. Where a service user (NHS and Independent Sector clients) undertook a Serious Incident Investigation (SI), the service aimed to contribute to the process and to support the NHS in preparation of the SI report. The service followed through on governance actions arising. In the case of a Coroner inquest, the Medical Director provided evidence on behalf of the service when requested by the coroner. The reporter could participate in the Inquests as separate witnesses. Where Duty of Candour (DoC) cases are identified, the reporters were invited to review their reflective responses in the light of a DoC process and the Medical Director provided a written statement on behalf of the service to the NHS for their preparation of a DoC response.

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.