Grove Park

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• 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

We assessed five quality statements from this key question. We have combined the scores for these quality statements with the rating from the last inspection, which was requires improvement. Our rating for this key question has improved and is now good. Staff and people told us that leaders were visible and approachable. Staff and people felt that senior managers listened to their concerns and took action. The hospital director had introduced a governance system that was being embedded. The staff team worked well together and with other organisations. The senior managers were developing a learning culture.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The senior leadership team at the hospital had the skills and experience needed for their roles. The Hospital Director told us that they had originally been employed to do consultancy work but had now taken on the hospital director role so they could help embed changes at the hospital.

Staff told us that senior managers were approachable, visited the wards regularly, so knew what was happening on the wards and acted when they needed to. For example, managers would support staff on the wards when people were distressed.

People told us they knew who the senior managers were and felt able to approach them if they needed anything.

Staff told us that the senior leaders at the hospital kept changing which affected consistency of approach. Under previous leaders the staff team had not always felt listened to. Since the new hospital director had been employed, they felt they would be listened to and action would be taking to address their concerns. They felt the new hospital director was introducing a more open culture that respected people and staff.

People told us that if they raised concerns with staff, they would address them and treat them fairly.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The hospital director had introduced governance structures that identified improvements and ensured staff took action to address them. The Governance framework had been in place for two months, so still needed fully embedding. Staff identified any action needed and assigned them to a member of staff to complete.

The governance meeting used an action tracker to audit progress against the action and to identify any lessons learnt. The Governance meeting linked with the hospital team meeting and the hospital health and safety meeting.

The governance meeting also reviewed the hospital’s risk register. The hospital director decided what items would be included in the risk register, but any member of staff could refer items to the risk register for the hospital director to consider.

Staff held community meetings on the wards which gave the people the opportunity to say if they felt safe or not. Staff asked the people what changes would make them feel safer and how they could improve the hospital. People told us that staff asked if they felt safe and that staff were always looking for ways to improve the hospital.

The hospital director told us there had been an increase in complaints as they had improved how they recorded complaints. Before the improvements staff were only recording serious complaints.

People told us they were happy to raise complaints with staff and felt staff and leaders treated their concerns fairly.

We attended a multidisciplinary morning meeting, where staff reviewed the previous 24 hours. We saw that staff worked well together, treated each other with respect and looked to learn from any incident that happened.

Ward staff told us they felt they had good working relationships with the rest of the multidisciplinary team.

Managers told us they had good relationships with commissioners and were able to make recommendations about people’ future care. For example, commissioners were planning to discharge a person to an area where they would not receive the care they needed. The provider was able to influence this decision and the commissioner agreed a new discharge plan.

The provider links with a local NHS trust and attends quality improvement meetings with them. Senior managers describe this as a supportive relationship.

Managers told us that the provider had sent them on leadership training and that they were supported with their continual professional development.

The provider had a lessons’ learnt meeting and used reflective practice to improve the care they provided.

The provider used audits to drive improvement, they currently undertook audits on, medication, physical environment, incidents and emergency equipment. The hospital director told us that audits had shown staff were not always reporting near misses. To address this, they were educating staff on how learning from near misses could help prevent more serious incidents happening.

There was a quality improvement project around discharge letters, ensuring they had all the correct information so that new providers or GPs could provide the correct care.