Passmores 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

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

This service scored 82 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

Staff felt respected, supported and valued. They said the service promoted equity and diversity in daily work and provided opportunities for development and career progression. They could raise any concerns without fear.

During the inspection we spoke to a newly appointed member of staff who said they had a very thorough induction plan, and they had been made to feel very welcome by managers and staff.

In 2024, the provider was a finalist for two categories in the Investors in People (IiP) Awards for 2024. They were shortlisted in two categories: Third Sector Employer of the Year and UK Employer of the Year.

The service had inclusive leaders with the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

Leaders were visible in the service and approachable for people and staff. We spoke with 8 members of staff. All the staff we spoke with said that the registered manager and other senior leaders were both approachable and engaged well with staff and people.

Senior managers engaged with staff on how to improve the service. Staff told us managers gave them opportunities to make suggestions on how to improve the service.

Staff could apply for funding to complete courses which could enhance their skills. For example, 3 recovery practitioners were training to use acupuncture with people using the service.

Managers engaged with people to gain feedback on how they could improve the service. They asked people to give feedback after completing treatment.

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

The provider had a whistleblower policy, which emphasized that all employees should feel comfortable raising concerns and sharing suggestions for improvement. All the staff we spoke with told us they felt confident in speaking up and in raising concerns or making suggestions for improvements.

The service worked towards an inclusive and fair culture by improving equality and equity for people who worked there.

The provider had a diversity, equity and inclusion policy and an anti-bullying and harassment policy. Both were being reviewed at the time of inspection. Staff were being consulted as part of this review and asked if they had any feedback or suggestions for changes or additions.

The provider had a number of diversity and wellbeing networks which staff could join.

The provider had a flexible working policy. Staff were able to work flexibly where appropriate.

Managers put reasonable adjustments in place for staff members to help them carry out their role.

The service had clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support.

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

Wider management meetings were held bi-monthly. This meeting was chaired by the Operations Director and provided a strategic overview to the running of the service. A service management meeting was held weekly and was chaired by the Clinical Director or Operations Director. This meeting covered standard agenda items and discussed clinical and operational issues, incidents and facilities.

Staff had implemented recommendations from reviews of incidents, complaints and safeguarding alerts. For example, we saw that managers had thoroughly investigated an incident where a person slipped and fell on a wet floor, including reviewing CCTV, and had highlighted lessons learnt and taken action to prevent a re-occurrence.

Staff maintained and had access to the risk register. The risk register for the service included 11 open risks. These included the risk of information technology failures, staff absences causing delivery concerns and unplanned discharges. The risk register included a rating for the severity of each risk; actions being taken to address the risk (including immediate mitigation) and timescales for completing those actions.

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

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

The service understood its duty to collaborate and work in partnership with, so the service worked seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

The service worked well with other agencies including referring agencies, health and social care professionals and the local authority safeguarding teams. We saw examples of positive feedback given by staff at referring agencies regarding their experience of working with staff at the service.

The head of psychology met with other heads of psychology within addiction services to share information and collaborate for improvement.

Senior managers attended The Collective Voice Tier 4 Services Forum which brought together representatives from voluntary sector drug and alcohol treatment and recovery services (both community service providers and Tier 4 service providers), to work collaboratively to improve access to and the provision of Tier 4 services.

The service focussed on continuous learning and improvement across the organisation.

The service had a positive approach to improvement and learning from incidents. Managers conducted thorough investigations after all incidents or concerns, not just serious ones, and shared learning and took action to prevent reoccurrence.

Innovations were taking place in the service. For example, the service had developed an innovative approach to the treatment of chemsex and ketamine dependence.

Managers maintained oversight of feedback using surveys and used it to inform changes and improvement of the service. For example, the service had appointed a life skills co-ordinator in response to people asking for more activities at evenings and weekends.

Staff were undertaking a review of the care plan, risk assessment associated management plan templates, including sharing proposed templates with people using the service and seeking feedback.

The psychologist regularly attended national addiction psychology meetings to meet and discuss issues and challenges.