MindOf

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

We rated well-led as Good because:

The service worked together as a team to ensure that patients received a high quality, responsive and efficient service. Structures, processes and systems to support good governance and management were effective.

Staff were aware of and understood the vision, values and strategy and their role in achieving them and they felt respected, supported and valued. They were proud to work for the service.

There was a focus on continuous learning and improvement within the service, including using patient feedback to improve the service.

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 service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

There was a clear vision and set of values which emphasised providing a high-quality service that was responsive, holistic and person-centred. There was a strong focus on collaborative working with individual patients and their families.

Staff were aware of and understood the vision, values and strategy and their role in achieving them.

The service monitored progress against delivery of the strategy. Staff demonstrated enthusiasm and passion to improve the service and to provide the best service possible to patients and their families.

Staff said they felt respected, supported and valued. They were proud to work for the service. The culture of the service focused on meeting the individual needs of the patients and their families.

Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems in place to ensure compliance with the requirements of the duty of candour. The registered manager ensured that all staff remained up to date with best practice.

Leaders had the capacity and skills to deliver high-quality, sustainable care.

The service was led by the registered manager who was also a consultant psychiatrist. They worked closely with the team and were knowledgeable about issues and priorities relating to the quality and future of the service.

Staff could describe how the service worked to ensure that patients received a high quality, responsive and efficient service.

Consultant psychiatrists and therapists were very established in their field and had practiced within their field for at least 10-20 years.

Staff described the registered manager as being visible and approachable within the service. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.

The registered manager understood the challenges within the service and were already addressing them, such as screening tools not being frequently completed.

Staff we spoke with said the service had a positive culture of speaking up and staff felt safe to do this and confident that any concerns would be heard and responded to. They described a strong emphasis on the safety and well-being of all staff.

Staff knew how to raise concerns, and we saw evidence of these processes being used effectively. The service had a whistleblowing g policy in place.

The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally. The service had put flexible working arrangements in place for staff that had requested this. Staff were able to join meetings remotely.

There were processes for providing all staff with the development they needed. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff also took part in weekly peer reviews to discuss and reflect on their clinical practice. Staff were supported to meet the requirements of professional revalidation where necessary.

Clinical, administrators and therapy staff were all considered valued members of the team. They were given protected time for professional development.

There were clear responsibilities, roles and systems of accountability to support good governance and management.

Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The service held daily stand-up meetings, weekly governance meetings and weekly case clinics. Leaders had access to reliable data on performance, risks and outcomes which they used to maintain safe care and drive service improvement.

Staff understood their roles and accountabilities and received support and supervision to perform well.

Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

There was an effective process to identify, understand, monitor and address current and future risks including risks to patient safety. The risk register for the service was kept up-to-date and the risks were reviewed at weekly clinical governance meetings.

The service had a business continuity plan in place in case of unexpected issues within the service, such as staff shortages.

The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions.

Leaders had oversight of safety alerts, audits, feedback, incidents, and complaints. These were discussed in the weekly governance meetings.

Clinical audits had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality. This enabled them to monitor the effectiveness of the treatment provided. For example, the clinical prescribing audit detailed what prescribing trends to be aware of and what areas needed to be further improved.

Quality and operational information was used to ensure and improve performance. The information used to monitor performance, and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses, such as improving the frequency of staff completing screening tools. Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.

The operational aspects of the service were discussed in the daily stand-up morning meetings, such as queries over prescriptions, fees and lunch break cover for the day. Any identified actions were allocated to a certain staff member to complete.

The service submitted data or notifications to external organisations as required.

There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems. The service used encrypted systems to ensure data was kept confidential and secure.

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

The service encouraged and heard views and concerns from parents, patients, staff and external partners and acted on them to shape the service and culture. Feedback was obtained through questionnaires during treatment and results were reviewed by the registered manager.

Patients and parents were also able to feedback through the service through a paper and electronic feedback form or send an email to the service. Positive feedback was displayed on the providers website.

Patient feedback was reviewed by staff in the weekly governance meetings and used to make improvements to the service. The service had recently improved the feedback template to include a link to the CQC give feedback on care form.

Clinicians made appropriate and timely referrals to external services in line with protocols and up to date evidence-based guidance. Staff gave examples of referring to the Child and Adolescent Mental Health services (CAMHS) and local occupational therapy services.

Records showed that where liaison was required with external services, this was carried out promptly and appropriately.

There were evidence of systems and processes for learning, continuous improvement and innovation.

Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance. Managers had created job plans with staff to explore what area staff were interested in developing further in relation to their career development, such as clinical audits.

There was a focus on continuous learning and improvement within the service. The service was utilising Artificial Intelligence to see how they could make the booking process clearer for parents and young people.

The registered manager was part of a Royal College of Psychiatrists’ network alongside their peers. The consultant psychiatrist took part in the network’s continuing professional development programme. This included attending seminars in person and webinars.