St Andrew's Healthcare - Essex

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 rated this key question as good. At this assessment the rating has remained
as good. This meant the service was consistently managed and well-led. Leaders and the culture they
created promoted high-quality, person-centred care.

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 provider as 3. 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.

The provider’s senior leadership team successfully communicated the provider’s core values - ‘compassion, accountability, respect, and excellence’ to the frontline staff in this service. Staff were able to identify these and demonstrated these values in their day-to-day work. Staff were enthusiastic and passionate about supporting patients and demonstrated the values in their work.

Senior leaders visited the services regularly and staff described them as supportive, approachable, and responsive. Senior leaders interacted and spoke with patients whilst visiting the wards and patients all knew who they were and what their names were.

All staff told us they felt respected, supported and valued. They said the service promoted equality and diversity in daily work and provided opportunities for development and career progression. Staff could raise any concerns without fear and would have no hesitation to do so.

We scored the service as 3. 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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The provider leadership team was well-established and worked effectively together.

Leaders had the skills, knowledge and experience to perform their roles, they had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

Leaders were visible in the service and approachable for patients and staff. All the staff said that managers were hands on with patients, supportive, approachable and led by example.

Staff development was supported through access to further training and courses. Staff we spoke with reported that the provider offered opportunities for ongoing learning and professional development.

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

The provider had a "Freedom to Speak Up" policy, which emphasized that all employees should feel comfortable raising concerns and sharing suggestions for improvement. There was a Freedom to Speak Up Guardian who supported the staff alongside two ambassadors and the hospitals leadership team. The Freedom to Speak up Guardian provided support and advice to staff who speak up, feedback on investigations and took action if patient safety was compromised.

All line managers completed a national E‑Learning for Health Freedom to Speak Up module. This training helped managers develop the skills to respond effectively to concerns, recognise common barriers, and provide clear, constructive follow‑up.

All the staff told us they felt confident in speaking up and in raising concerns or making suggestions for improvements.

Patients and staff could meet with members of the provider’s senior leadership team to give feedback. For example, patients provided feedback at the clinical governance meeting and feedback was sought from staff at breakfast meetings.

Staff knew how to use the whistle-blowing process and felt able to raise concerns without fear of victimisation. Staff described an open and supportive culture where they were encouraged to speak up and raise concerns.

We scored the service as 3. 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.

The service had an up-to-date diversity and inclusion policy which aimed to ensure that staff put diversity and inclusion at the heart of everything they did and to highlight the commitment that St Andrews made to promoting equality and preventing discrimination at work.

The service employed a diverse team of staff. Employment practices promoted equality of opportunity. Managers said the service did not discriminate against staff from minority groups. Staff did not raise any concerns about discrimination and all the staff we spoke with said they were treated fairly and had good opportunities for personal and professional development.

The service had a range of employee networks, which included: PRIDE - an active LGBTQ+ network, DAWN - a disability And wellness network employee group focussed on promoting equality of opportunity and positive attitudes towards people with disabilities, WiSH network - women in St Andrew's Healthcare and the UNITY Network - open to staff from across the charity from all ethnic backgrounds, allies and people interested in exploring and supporting the experiences of people from diverse backgrounds in healthcare.

Staff were able to apply to work flexibly, for example, flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

We scored the service as 3. The provider 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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Our findings from the other key questions demonstrated that governance processes operated effectively at team level and that performance and risk were managed well. Governance arrangements were proactively reviewed and reflected best practice.

Managers held monthly ward and divisional clinical governance meetings. We looked at the minutes for the previous 3 meetings and could see the agenda was comprehensive, areas of concern were identified, and actions were identified. The divisional meetings were chaired by the hospital director and covered standard agenda items including patient and carer experience, safety and quality compliance.

Staff had implemented recommendations from reviews of incidents, complaints and safeguarding alerts. Managers identified lessons learnt following an incident where a patient utilised unescorted leave to bring illicit substances onto one of the wards.

Staff undertook or participated in clinical audits. The service employed a quality matron whose role was to maintain high standards of care through structured audit processes and ongoing quality assurance. Staff undertook a series of focused audits, including care plan reviews, care coordinator sessions, enhanced support care plans, and patient community meetings. Through the audits, staff were able to identify areas of good practice, as well as opportunities for improvement.

Staff maintained and had access to the risk register. The risk register for the hospital was up to date and included the risk of patients’ self-harm, recruitment and retention and patients’ physical health needs. The risk register included a rating for the severity of each risk and control measures to mitigate against the risks.

The service had contingency plans for emergencies, for example adverse weather or outbreaks of infectious diseases.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system worked and well and helped to improve the quality of care.

Managers had access to information to support them with their management role. This included dashboards which included information on the performance of the service, staffing and patient care.

We scored the service as 3. The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service worked well with other agencies including commissioning bed managers, health and social care professionals and the local authority safeguarding team. For example, the service understood the key priority areas for local safeguarding referrals.

Staff maintained community partnerships and worked with local organisations to support patient care and learning opportunities. For example, sport for confidence, the recovery college and new life wood.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. We saw evidence that staff felt comfortable providing feedback and expressing their opinions.

We scored the service as 3. The provider 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 contributed to safe, effective practice and research.

Managers and staff shared lessons learnt after incidents and met to discuss incidents and make improvements.

Staff used quality improvement methods and knew how to apply them. The service had a quality improvement plan and equality, diversity and inclusion improvement plan.

Staff participated in national audits relevant to the service and used the findings to support continuous improvement.

A member of staff had conducted research and published a paper which reported findings from the first-year pilot of the multi-dimensional trauma-informed recovery long-term (MDTIR-LT) programme, implemented as part of a service development, delivered across Danbury ward.