The Spinal Unit Action Group

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

Well-led – 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 good. At this assessment the rating has changed to requires improvement.

This meant the management and leadership was inconsistent. Governance systems and processes did not always support the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service. Governance and oversight processes were not effective at ensuring people received safe and high-quality person-centred care.

This service scored 57 (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. 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 had a good understanding of the visions and values of the service; they described good morale and teamwork amongst the staff group at all levels. A member of staff told us, “We aim to do the very best we can for everyone living here” and “It’s a great team of managers and staff, and we all get on.”

Not all leaders understood the context in which they delivered care, treatment and support. We were not always assured the provider fully understood their responsibilities for ensuring robust governance and quality assurance systems and processes. However, staff told us they felt managers listened, showed compassion, were open and honest and kept them up to date with any changes to the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. For example, people and staff told us they were not afraid to speak up and were confident they would be listened to. We saw examples recorded in minutes of ‘resident’s’ meetings where people had freely expressed their views. Staff told us they were confident about approaching both the registered manager and deputy manager with any concerns or other matters relating to their work.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they were treated fairly and felt valued and included. For example, staff provided examples of adjustments made, such as flexible working patterns to accommodate their personal circumstances.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this with others when appropriate. The governance systems and processes did not effectively assess, monitor and drive improvement in the quality and safety of the service. For example, audits and checks for reviewing the quality and safety of the service were either not completed or regular. We found a lack of audits and checks in relation to risk management, safety of the environment, portable appliances, fire safety procedures and staff supervision and appraisal. Where information was gathered it was not analysed and responded to, including information about accidents and incidents and complaints. Monthly quality visits undertaken by representatives on behalf of the provider lacked oversight and scrutiny as they failed to identify a lack of robust governance and assurance systems and processes.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Improvements to the service identified by other stakeholders were not always acted upon. For example, the local authority identified areas for improvement during an assessment they completed in April 2024, however recommendations they made remained outstanding. In addition, recommendations made by the local fire authority in June 2024 also remained outstanding.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. There was no formal process in place to continually evaluate the service and drive improvement. This was despite us and other stakeholders identifying multiple areas for improvement across the service. For example, staff supervision and appraisal processes were not carried out when required limiting opportunity for them to learn and develop within their role. Whilst people and staff were able and confident to express their views about the service there was no formal process for gathering and acting on their feedback as part of the service development.

Following our assessment site visit the provider shared with us an action plan they devised to address the required improvements.