Dartmouth 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

At our last assessment we rated this key question as good. We looked for evidence that the service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This key question has been rated as good. This meant the service was consistently managed and well led. Leaders implemented improved governance processes to ensure oversight and identified any risks which were then acted on. Leaders were visible and led by example. Leaders actively promoted staff empowerment to drive improvement. They encouraged staff to raise concerns and promoted the value of doing so. Staff and leaders had a good understanding of how to make improvement happen. Leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and their communities.

Staff were aware of the vision and values of the organisation and how their role helped to achieve these. Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding.

Leaders made sure staff felt valued and knew that they mattered. Staff spoke of the annual staff appreciation day and felt this helped them to feel included and appreciated. They also spoke about the quarterly employee award and how this encouraged them to achieve this and helped to foster teamwork.

Staff understood equality, diversity and human rights. Equality and diversity were actively promoted, and the causes of any workforce inequality were identified with action taken to address these.

The provider 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. They had the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

Leaders had the experience, capability and integrity to ensure the organisational vision could be delivered and risks were managed. Staff told us how the manager was visible and led by example. There were monthly staff meetings and minutes of these showed they were well attended by a range of staff. The provider paid staff to attend meetings if they were not rostered to work that day.

Leaders were knowledgeable about issues and priorities for the quality of the service. They could access leadership training and were encouraged to do so.

Leaders were alert to any examples of poor culture that might affect the quality of people’s care and have a detrimental impact on staff. We saw that they addressed this quickly.

The provider created a positive culture where people felt that they could speak up and that their voice will be heard.

There was a culture of speaking up where staff actively raised concerns and those who did were supported, without fear of detriment. We saw an example of where staff had raised concerns, and these were investigated by managers and action was taken to improve the culture of the service.

At each of the provider’s services there was a contact for staff to raise any concerns to as well as the operations director. Staff knew who to contact if they had concerns and told us they were listened to when they raised concerns.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders acted to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. Staff told us that any racism or hate speech was taken seriously and they were supported by managers to report this. Staff said that the expectations of behaviours were regularly discussed with staff and people who used the service and if these were not met then leaders challenged this.

Leaders take active steps to ensure staff and leaders are representative of the population of people using the service. The workforce was diverse which represented the people who used the service.

Staff told us they were supported with their protected equality characteristics. For example they were provided with facilities to pray during their working hours as well as supported with fasting times to meet their religious preferences.

The provider had clear responsibilities, roles, systems of accountability or good governance. They acted on information about risk, performance and outcomes.

There were clear and effective governance, management and accountability arrangements. Staff understood their roles and responsibilities. Community meeting minutes showed that actions agreed were followed up. There was an audit programme and staff completed these. Audits showed that actions were taken to improve the service where needed. The registered manager was aware of what was on their risk register and had a plan to reduce these.

Data or notifications are consistently submitted to external organisations as required including the Care Quality Commission and local integrated care board.

There were robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. Staff received training in information governance.

The provider understood their duty to collaborate and worked in partnership, so their service worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies. Leaders described positive relationships with the local Integrated Care Board (ICB), local authority and Mental Health NHS trust. The provider was working hard to improve collaboration from the local authority because some people needed their intervention when they were ready to be discharged from the hospital. Staff and leaders were involved with charities and religious institutions within the community. They developed relationships with these groups so that people using the service could engage with their communities.

The provider focused on continuous learning, innovation and improvement across our organisation and the local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Staff and leaders had a good understanding of how to make improvement happen. There were processes to ensure that learning happened when things went wrong, and from examples of good practice. Staff told us how they learned from incidents not just at Dartmouth House but across the provider’s services. They had put in place end of shift debriefs where they had an open discussion about what went well, what did not go so well and what they could do to improve. They said this continuous reflection helped to improve the service.

Leaders encouraged staff to speak up with ideas for improvement and actively invested time to listen and engage. Staff had weekly reflective practice sessions with the psychologists. At these sessions they focused on a person, their care plans and risk assessments.