CIPHER Medical

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

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 did not rate the service. At this assessment the rating is good

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.

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.

The service had a clearly defined mission and vision that was well understood across the organisation. Their mission was to deliver a safe and effective service which centered on patient care. The vision emphasises teamwork, collaboration and a drive for excellence ensuring that all staff work together as one team to positively impact every life they touch. This shared direction was communicated through induction, ongoing training and leadership visibility.

The organisation`s culture was underpinned by a set of values that guided behaviour, service delivery and decision making. These values were based on openness and accountability, pride, respect and dignity. Leaders and staff understood and contributed to the organisation’s values.

This shared direction was reflected in the way leaders discussed incidents, learning and performance through governance meetings and in the positive collaborative culture we observed across the service.

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 organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders were experienced, knowledgeable and demonstrated the skills and abilities to run the service. They understood and managed the priorities and issues that the service faced and were committed to delivering safe, high-quality care. Leaders were visible and approachable and actively involved in the governance processes. Staff felt the leaders supported them to develop their skills and take on more senior roles.

Leaders had taken incidents seriously and knew how to deal with concerns when raised which promoted a positive culture in the service. Leaders undertook patient facing activities to assess for themselves how the service was running.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns and share ideas and told us they felt confident that their voices were heard.

Staff described having clear routes to raise concerns about their work or how the service operated. The service had an established Freedom to Speak Up policy and a named Freedom to Speak Up Lead and several FTSUG champions who staff could contact directly.

Records showed that over the last 12 months, four concerns had been raised. Three concerns had been investigated, and one had been escalated to the Head of Clinical Services for further review and resolution.

The service had a structured approach to supporting staff voice. Each department, including urgent and emergency care and the patient transport service, had dedicated staff speak-up representatives. These representatives acted as accessible points of contact for colleagues and promoted a culture where staff could raise concerns without fear of retribution.

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.

The service had an Equality, Diversity and Inclusion (EDI) policy which referenced the Equality Act 2010 and the provider’s responsibilities to prevent discrimination and promote equality of opportunity. The policy set out expectations around reasonable adjustments and inclusive practice.

The service had a civility, respect and resolution policy which set out clear expectations for professional behaviour, dignity and respect and was aligned with the provider’s values. Staff consistently told us they felt respected and valued. They felt supported by their managers when they requested adjustments and flexible working. Staff give us examples where managers had responded with compassion to personal or family related issues.

The provider also recognised the challenges staff may face during their employment and had statutory policies in place including:

• Neonatal leave and pay policy
• Maternity policy
• Paternity policy
• Adoption policy
• Shared parental leave policy

These policies clearly outlined processes, entitlements and support that were available and accessible to staff. Staff told us they understood how to request support if needed.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate, However governance processes did not consistently provide the same level of assurance for medicines management.

The service had clear responsibilities, roles and systems of accountability that supported safe and sustainable care. Leaders used structured governance process to monitor risk, performance and quality.

Leaders met regularly through structured governance meetings attended by senior decision makers. Across the last three governance meetings, leaders followed an agenda that covered significant key areas which included clinical incidents, safeguarding, equipment concerns, complaints and compliments. We saw evidence that leaders reviewed ongoing incidents, action logs and outcomes at each meeting. These updated actions were recorded and monitored. For example, sedation practice was reviewed, policies updated and cases were presented for learning.

IPC was a standard agenda item at the providers monthly clinical governance meeting. Leaders reviewed audit outcomes, compliance and any emerging risks. For example, a recent rise in local tuberculosis cases was discussed, and the provider used this as the monthly learning topic on staff boards, signposting staff to relevant national guidance. Audit findings, incident themes and compliance updates were routinely reviewed and actions tracked through effective governance processes. Overall, this demonstrates strong oversight, proactive risk management and a commitment to ensuring staff remained informed about current IPC risks.

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.

The provider worked well with system partners and demonstrated a commitment to contributing effectively to the wider healthcare system. Leaders engaged effectively with NHS and non-NHS partners to support safe, coordinated care across the region.

During the onsite assessment, we joined a system call between the provider and the NHS ambulance trust as part of a standard contract meeting. The discussion focused on mask wearing requirements, IPC expectations and vehicle cleaning standards in response to winter infection pressures. The NHS ambulance trust explained the rationale for recent changes to practices including the use of a risk assessment tool to determine when mask wearing should be introduced and how it would be later stepped back. The provider confirmed they would implement the NHS ambulance trust approach and ensure compliance. Leaders engaged openly and collaboratively and demonstrated a proactive and solution-based approach.

As part of the assessment, we sought feedback from the integrated care board (ICB) and NHS trusts. Partners consistently described the provider as professional, responsive and patient focused. They reported positive communication, good collaboration and no outstanding concerns or unresolved incidents. Examples were given of crews going the extra mile to ensure a positive patient experience. Examples included crews that assisted patients who were not yet ready for transfer, providing reassurance and supporting ward staff during complex discharges.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Learning was shared effectively across the organisation. Staff received regular bulletins highlighting incident themes, updates from partner organisations and changes to practice. We also saw evidence of staff learning boards which displayed topic of the month materials and key safety messages. Staff told us these boards helped keep learning visible and reinforced expectations in daily practice.

The provider had implemented a range of QR code systems to support learning, reporting and operational improvement. QR codes were displayed throughout the building and inside the ambulance vehicles, giving staff immediate access to key tools and information. These included:

• Incident reporting forms
• Safeguarding referral forms
• Equipment manuals and guidance
• Vehicle and equipment fault reporting forms.
• Medical training vehicles.

Staff told us that QR codes made it easily accessible to report concerns, access information and escalate issues in real time. Data gathered through the QR codes system identified themes and trends. Leaders actively focused on reinforcing learning to strengthen safety and quality.