3 The Beeches

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 inspection we rated this key question as requires improvement. The service was in breach of Regulation 17 in relation to a lack of relevant and up to date policies, no vision and values, lack of robust governance and quality assurance processes including a risk register. The service had made improvements and was no longer in breach of the regulations identified at the last inspection. Staff could now access policies and procedures, which were regularly reviewed. The service now had a vision and values that staff were aware of. The service now had robust governance processes, and a risk register that was reviewed regularly. 

At this inspection the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance. They used this to identify improvements.

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 service as 3. The evidence showed a good standard. The service 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 now had a stated vision for the service and three core values which were “trust”, “honesty” and “partnership”. The provider had actions under each of the values, which included actions that staff would implement in practice. The provider had four strategic commitments to embed their vision and values. These were “innovation in brain health”, “accessibility and equity”, “family and community involvement”, and “staff wellbeing and development”. 

Staff were aware of the service’s purpose statement, and vision and values. Staff had the opportunity to contribute to discussions about the strategy for their service. Staff told us there was an open culture within the service. 

We scored the service as 3. The evidence showed a good standard. The service 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.

Leaders had the skills, knowledge and experience to perform their roles, and a good understanding of the services they managed. They could explain clearly how the service worked to provide high-quality care. The service was founded by the medical director, who continued to work in the service. 

Staff told us that managers were very supportive. Leaders were visible in the service and approachable for patients and staff. They were friendly and encouraged staff to work together as a team, regardless of role. There was good communication and staff were clear about their roles and accountabilities. Staff felt supported when they were off sick. 

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

Managers told us they promoted an open culture and people could raise concerns. There had been no whistleblowing concerns raised. Staff had the option of providing anonymous feedback through an independent website, but there had never been any comments left there.

Staff understood the provider’s whistleblowing policies and felt comfortable using them without fear of reprisal. Staff told us they were aware of the whistleblowing process and felt able to raise any concerns they had. Staff felt able to speak up and express their views. 

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service had equality, diversity and inclusion policies, which all staff had completed training on.

Managers put reasonable adjustments in place for staff members to help them carry out their role. Staff had access to flexible working arrangements to account for personal circumstances such as caring responsibilities and health issues. Many staff mostly worked from home, and office-based staff had access to this. 

We scored the service as 3. The evidence showed a good standard. The service 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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service now had a robust clinical governance process. Managers held a monthly clinical governance meeting which was attended by managers and specific clinicians if necessary. Managers also held a weekly meeting, where they reviewed day to day issues in the service. Minutes were stored on a shared drive that was accessible to all staff. There was a standard agenda which included policies, new guidance or research on ADHD or related areas, and any reports and ongoing actions from incidents, safeguarding or complaints. The service had 2 electronic systems for recording and tracking of information. Staff acknowledged that although there may be some duplication, having the 2 systems provided them with the ability to review and track information in a meaningful way.

Staff now undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. The provider had an audit schedule and tracker that was stored online and was accessible by staff. There was an audit report dashboard. The provider carried out audits of aspects of the service which included completion of care records, and timeliness of the process. This showed that the care pathway was monitored and reviewed regularly, and that action was taken if there were any gaps or delays. This was reviewed in the weekly meetings and through the governance process. 

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

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. Information governance systems included confidentiality of patient records. 

All staff had completed information governance training. The provider had systems for the security of its records systems and general IT security, which included for staff who worked from home. The service securely stored any paper documents. The provider had comprehensive policies about confidentiality and the security of information. The provider was registered with the Information Commissioner’s Office (ICO) and knew how to contact them for advice or if there was an information breach. If an issue occurred this was investigated and action was taken. There had been a recent example of information being sent to the wrong GP. The service had not been at fault but took action to reduce the risk of this happening again. 

The provider maintained a risk register. There was one high risk about problems with courier companies used for the delivery of prescriptions. Other risks were identified as medium or low and related to potential or specific risks such as increased demand on the services, staff shortages, negative feedback and complaints. There were actions to address or mitigate these risk and timelines for review. Staff concerns matched those on the risk register. 

The service had plans to ensure the business could keep running in the event of adverse incident. For example, staff maintained dual records in the event of computer or internet failure, and backups for the phone and IT systems. If there were problems with the building, such as power outages, staff could work from home. Managers told us that they do not provide an emergency service, and their plans included ensuring that in the event of the service not being able to run as normal they would communicate with patients and staff, so they knew what was happening. 

The service now had policies and procedures that covered all aspects of the service and had regular review dates and version controls. They were stored online and were accessible to all staff. 

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Staff referred to external healthcare services if a patient had increased risks or complexity that could not be managed or treated in the service. 

Staff worked in collaboration with the Integrated Care Board (ICB) and the NHS. The service worked with an ICB to deliver training about attention deficit hyperactivity disorder (ADHD) to primary care services. 

Staff provided a programme into a school, linked in with schools regarding Education, Health and Care Plans (EHCPs) and liaised with Special Educational Needs Co-ordinators (SENCOs) when necessary. Staff also provided education to schools and organisations. This work was delivered free of charge through Sanctum Brain Health CIC, without commissioning or external funding 

We scored the service as 3. The evidence showed a good standard. The service 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 contribute to safe, effective practice and research.

Innovations were taking place in the service. 

The provider had developed a “Brain Health” model. This was a holistic approach that included sleep, stress, hormonal factors, mood and emotions, behavioural and physical health. The model built upon NICE guidance and referenced other research to create an evidence-based approach that was continuing to develop. 

A number of initiatives were taking place in the service. 

The provider was trialling the use of wearable technology with patients, such as monitoring sleep patterns and disturbances. Patients used an app that could share this with staff, and they could then analyse this information. 

The provider had a post-diagnosis education platform or ‘course’, that patients could access to find information about their condition and the treatments and support available. This was audited to see how often people are accessing the platform, which could show if people were accessing the information and if so what was of interest to them, and how it could be tailored to them. 

The provider was developing a 12-week education programme called ‘Menopause Brain’, which focused on the specific needs of women with attention deficit hyperactivity disorder (ADHD) who were experiencing the menopause. 

The provider had produced a Brain Health Report, which was a summary of information from 1,324 survey respondents who had completed their screening tools. This had been presented at an international ADHD conference. 

The service had set up Sanctum Brain Health CIC (Community Interest Company), which was looking at populations without access to these services. It had piloted a project for children subject to the pupil premium. The pupil premium is a government grant that provides additional funding for state-funded schools in England to raise the educational attainment of disadvantaged pupils, which included looked after children and children who receive free school meals. The service had a working group that they were developing with the school to raise staff awareness of working and supporting children with ADHD.