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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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing and could explain how they were working to deliver high quality care within the budgets available.

The service held ‘Kite awards’ which reflected the values of the organisation. Staff could be nominated and receive their award along with vouchers and small gifts such as chocolate. Staff told us they were mentioned in service wide literature, and they felt proud of the recognition of their efforts. Wards also had employee of the month awards.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organization. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. All staff told us they had confidence in senior leaders. Staff said senior leaders have an open-door policy and a visible presence on the wards. Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

Senior leaders were visible in the service and approachable for patients and staff. Patients told us 2 directors came to the service for a BBQ the day before our inspection and the service manager sometimes says hello, though it is normally just the ward staff.

Leadership development opportunities were available, including opportunities for staff. The service’s clinical director has established a hour for staff every Thursday to pursue compulsory professional development (CPD) which has been well received by staff. Both service managers have completed Level 5 Leadership and management courses, which they supplemented with incident system monitoring and a monthly safety meeting to identify themes and trends and generate learning opportunities.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Ward managers told us there is an open and honest culture and they encouraged all staff speak up. Staff knew who their FTSU guardian was and how to access this if they needed to raise concerns and Ward staff told us they felt safe to raise complaints and concerns.

The service is covered by a corporate Freedom to Speak Up (FTSU) guardian who visits the service as required and to promote the offer. The service had 3 FTSU concerns shared in the last 3 years and conducts and annual ‘closed culture’ audit, which found no major concerns.

Patients and carers had opportunities to give feedback on the service they received through the friends and family survey, but so far have received only one response. Patients and relatives preferred to give feedback directly to staff and via the family liaison lead which was universally praised by patients and staff alike.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

There were equality and diversity champions within the service for staff, and the provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. Staff were very complementary of flexible working adjustments to account for personal circumstances such as caring responsibilities and health issues. Managers had put reasonable adjustments in place for staff members to help them carry out their role.

We scored the service as 4. The evidence showed an exceptional standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required, citing the safe management of patient leave close to the motorway as one example.

The service had plans for emergencies including emergency power generation, which had worked during recent Winter storms and evacuation preparedness for a flood, caused by nearby building works, which was averted, but the service was ready.

The service has not allowed costs to compromise patient care, investing in fencing to provide privacy for patients from the main road and installing roll top roofing around the first floor to minimise climbing risks to low secure specifications.

Staff had access to the equipment and information technology needed to do their work, using systems to collect data from wards that were not over-burdensome for frontline staff. Staff were complementary of management interest and support to simplify and tailor various templates around care planning and patient leave to reduce administrative burden and highlight key information. Information governance systems included confidentiality of patient records with password protection and limited staff access.

Elysium is working towards net-zero carbon emissions through a formal Carbon Reduction Plan and developing an Environmental Management System (EMS) aligned with ISO 14001 principles to improve energy efficiency within buildings and facilities and reducing travel-related emissions by increasing the use of video conferencing.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Directorate leaders engaged with external stakeholders such as commissioners and Healthwatch and patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff told us they could access specialist training in addition to their mandatory training program. All occupational therapy staff have completed sensory needs training based on patient need increasing. One ward manager had completed a leadership training program. Some staff were hired following apprenticeships and another staff had phlebotomy training at their request.

The service holds weekly teaching sessions for staff. Senior leaders, Allied Professionals and doctors have lead sessions on communication, antipsychotic medications, applying principles of the Mental Health Act in practice and preventing medication errors. The lead psychologist leads weekly reflective practice sessions for staff.

Innovations were taking place in the service where staff used quality improvement methods. Two quality improvement projects are underway, involving a peer- support project where this service is 1 of only 2 pilot sites companywide, and a seclusion quality improvement project arising from the service’s incident monitoring activity that noted a patient’s physical health was not as well monitored in seclusion as the service would have liked.

Kenn Ward was in the third round of Accreditation for Inpatient Mental Health Services (AIMS) which is a quality improvement and accreditation programme run by the Royal College of Psychiatrists' Centre for Quality Improvement (CCQI) and is half way through the Triangle of Care accreditation quality improvement program run by Carers Trust. Triangle of Care accreditation focuses on ensuring carers are recognised and supported as partners in care. It is based on the idea that the best outcomes occur when there is effective collaboration between the service user, the carer, and the mental health professional.