Cheadle Royal Hospital

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

Well Led:

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 Requires Improvement. The service was in breach of legal regulation in relation to Regulation 17 Good Governance. At this assessment the rating has remained Requires Improvement.

Requires improvement: This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

At this assessment, the service was in breach of legal regulation in relation to Regulation 17 Good Governance.

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 have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

• Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. They were shared in email footers. The vision was “Making a real and lasting difference for everyone we support.” The values were “Striving for Excellence, Being Supportive, Being Positive, Acting with integrity and Putting People First.”
• Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. The hospital director had led 2 huddles for staff at an external venue to update on progress made within the organisation and reflect on the position the service was in and to seek views from colleagues, the use of an online interactive platform was used for this.
• Staff could explain how they were working to deliver high quality care within the budgets available. Ward managers were aware of the focus to reduce the use of agency staff, to improve consistency for patients.

We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

• Leaders had the skills, knowledge and experience to perform their roles. The hospital director had been in position since May 2023. Staff told us that they had made positive changes in the governance and leadership of the service. They were approachable and visible within the service.
• Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Ward managers and directors of clinical services understood the wards, what was working well, where progress had been made and where there was still areas to improve.
• Leaders were visible in the service and approachable for patients and staff. We saw leaders on the wards during the assessment.
• Leadership development opportunities were available, including opportunities for staff. Ward managers spoke positively of the leadership skills training that was facilitated by the hospital director. We reviewed the evaluation which showed very positive feedback from attendees and how much they valued the training and had already started to implement some of the approaches.

People did not always feel they could speak up and that their voice would be heard.

• Patients and carers did not always have opportunities to give feedback on the service they received in a manner that reflected their individual needs. There was no carer’s survey for this service. Information was not available in other languages for patients whose first language was not English. This meant the service was not seeking feedback from all patients and carers.
• Managers and staff had access to the feedback from patients, via the community meeting minutes. However the healthcare patient satisfaction survey analysis was hospital wide, this meant staff did not know the results for their service or ward to support them to make any changes. The main themes from the staff survey for areas for improvement were; communication, increase job satisfaction, improve leadership skills and improve equality, diversity and inclusion support and understanding.
• Patients were involved in decision-making about changes to the service via the weekly community meetings. However carers were not involved in decision-making about changes to the service. There were plans to set up a carers meeting in 2025. There was a Lived Experience Partnership project being rolled out in 2025, with the aim of recruiting lived experience partners to be involved in governance, training, recruitment and induction of staff.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

• There were equality and diversity champions within the provider e.g. LGBTQ+. The weekly Cascade publication that had been created to share news, updates and learning from incidents included in its February 2024 edition the promotion of LGBTQ+ history month, related events and the encouragement for sites to set up LGBTQ+ networks or join the provider network. The November 2024 edition of Cascade included the promotion of a non-tolerance of racism campaign in the workplace.
• Staff were able to apply to work flexibly e.g. flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. We spoke with staff where these had been put in place.
• Managers put reasonable adjustments in place for staff members to help them carry out their role.
• The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. An anonymous survey had been introduced for staff during their induction to gather monitoring data and their feedback.

Quality Statement Score: 2

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

• There was not a clear framework of what must be discussed at a ward or team level, including in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. We reviewed team meeting minutes, they were variable across the wards and did not have standard agendas except Maple ward which included quality walk round, clinical governance updates, health and safety, policy updates, safeguarding, patient feedback and lessons learnt. This meant staff across the wards were not receiving consistent updates and learning from incidents and complaints.
• Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. This included the implementation of keeping safe care plans which we saw in care records.
• Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. The findings of these audits were reported in the monthly ward dashboards for each ward and reviewed as part of the monthly clinical governance meetings. Ward managers and senior managers reviewed these to monitor progress and areas for improvement.
• Staff understood the arrangements for working with other teams, both within the provider and externally, to meet the needs of the patients.
• Management of risk, issues and performance took place via monthly governance meetings on each ward. These were attended by the multidisciplinary team and included lessons learnt from incidents. Senior management meetings took place monthly, minutes showed they discussed progress from service improvement meetings at ward level, review of risk register, human resources and finance updates.
• Staff concerns matched those on the risk register. Medicines and environmental cleanliness that were identified during the assessment were on the risk register.
• The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff. Monthly submissions were collated by ward managers, they spoke positively of the improvement with oversight and support within the governance of the service.
• Staff did not always have access to the equipment and information technology needed to do their work. Staff told us that a lack of computers and lap tops made it difficult for them to fulfil their role efficiently. Stakeholders told us that the telephone system did not include the recently opened wards and when they did have direct numbers for the ward, it was very difficult to get through and calls were not answered.
• Information governance systems included confidentiality of patient records.
• Ward 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. Monthly dashboards were created and where there were identified areas for improvement, heat maps were created to show at a glance the progress they were making. Ward managers welcomed the introduction of these.
• Leaders did not ensure that staff followed provider policies in relation to dress code on the wards. On every ward, staff were not bare below the elbow, most were wearing fleeces, we also saw nurses with long sleeved tops on under their tunics. Staff had nail varnish on and false nails. Staff were not following the organisation’s policy, and managers were not ensuring the policy was implemented.
• Leaders did not ensure that staff followed the provider policy in relation to vaping. We observed patients openly vaping in communal areas on Alder ward, Maple ward, Evergreen ward and Featherstone ward, staff told us that patients can vape on the ward. The provider’s Smoke Free Hospitals policy states “12.8 (g) Vape users are expected to be considerate to those around them and always use the device when in an allocated and discreet area (e.g. hospital grounds, gardens or single bedrooms, but not communal indoor areas or during therapeutic groups and 1:1 sessions).” Staff were not following this policy, and managers were not ensuring the policy was implemented. Carers told us that they had to complain on behalf of loved ones due to the impact of other patients vaping on the wellbeing of their loved ones.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

• Leaders engaged with external stakeholders, such as commissioners and advocacy services. Stakeholders told us that the service, particularly senior leaders were responsive to their requests, this had been an improvement over the last year, with senior leaders being more proactive. An example was a significant improvement in the WIFI within the hospital, resulting in improved access for patients.
• Stakeholders told us that contact with the wards could be difficult at times, with new wards opening that were not on the switchboard out of hours and when a direct number was located, the call was not answered. Also ward emails were not always being responded to. Stakeholders told us they did not receive regular updates about patients if they were responsible for overseeing the placement. This could include discharge plans, changes to wards and levels of observations. This meant stakeholders were not fully informed about the patients that they placed at the service.
• Stakeholders told us that the service did not always check before starting meetings to see if external guests were waiting either remotely or in reception which has resulted in stakeholders missing meetings. Changes with dates and times of meetings such as ward rounds were not always communicated with stakeholders. Enabling external people to join meetings remotely was not always facilitated in a way that all present could participate in the meeting. This meant not all people involved in the care of patients were informed and involved in the progress of patient's admissions and recovery.
• Stakeholders told us that ward based staff did not always support patients with the actions following ward round, resulting on occasion, for example in missed referrals.
• There were no formal processes for carers to meet with members of the provider's senior leadership team. However there were opportunities for patients and staff to meet with members of the provider's senior leadership team via quality walk rounds, coffee with Kate, listening spaces and Cheadle Huddles. There were plans to set up a carers meeting in 2025. There was a Lived Experience Partnership project being rolled out in 2025, with the aim of recruiting lived experience partners to be involved in governance, training, recruitment and induction of staff.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

• Staff were not given recent time and support to consider opportunities for improvements and innovation. The provider had a quality improvement commitment to support people to be involved in quality improvement projects, however the clinical governance meetings for the last 6 months did not record any quality improvement projects that staff were involved in and there was an agenda item for this. However prior to this there had been quality improvement projects including impact of participating in weekend activities on wellbeing, promoting womens health, scenario based learning and named Health Care Assistants.
• Staff had opportunities to participate in research. We reviewed the clinical governance minutes for the last 6 months and minutes showed the Head of Psychology supporting a trainee Clinical Psychologist with research exploring the experiences of service users in inpatient services who have both diagnoses of Borderline Personality Disorder and Autism.
• Within the governance meeting, quality objectives were discussed. Minutes showed that there was a task and finish group in relation to the model of care.
• Staff did not participate in national audits relevant to the service. Minutes reviewed did not show involvement in any national audits.
• Wards did not participate in accreditation schemes relevant to the service, for example the Royal College of Psychiatry’s Quality Network for Psychiatric Intensive Care Units (QNPICU) or Quality Network for Inpatient Working Age Mental Health Services (QNWA).