Kemple View

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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

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 outstanding. At this assessment the rating has changed to good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.
• The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. The values were included in staff personal development reviews.
• Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing.

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.
• Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Managers had site handover meetings Monday to Friday, which supported their oversight of the service, including extended handovers on Wednesday and Friday to review areas such as safeguarding, physical health checks and the ward dashboard.
• Leaders were visible in the service and approachable for patients and staff. Leaders carried out monthly quality walk rounds and patient safety temperature checks to identify any concerns on the ward, which included checking the environment and speaking with staff and patients. However, these were not completed as regularly as planned. Managers also carried out monthly out-of-hours site visits and there was evidence of managers speaking to staff during these visits and identifying any concerns they had. There was also a daily duty manager list in place.
• Leadership development opportunities were available, including level 4 leadership training and nurse apprenticeship training.

• Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. There were a variety of mechanisms in place to enable patients to give feedback on the service. These included a complaints book and opportunities for patient representation in governance meetings. Patients could also raise concerns with their advocate, however, it was more difficult for patients to provide anonymised feedback. There was a feedback box in the family room which provided an opportunity for families and carers to share feedback. Carers were also given information about raising concerns in the family and friends’ information booklet.
• Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.
• Patients were involved in decision-making about changes to the service. For example, the service had a service user council, which discussed issues affecting the service including environmental issues and issues around the running of the ward. These were then discussed in the clinical governance committee.

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.

• The provider had a number of equality and diversity networks including LGBTQ+, Black and Minority Ethnic and parents networks and there were champions as part of those networks.
• Staff were able to apply to work flexibly e.g. there were flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.
• 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 is diverse in its make-up and representative of the patient group.

We did not always have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

• There was a clear framework of what must be discussed at all levels of the service to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. The provider had a ward to board approach. Staff had monthly team meetings and managers had weekly operational meetings and monthly ward managers meetings. These linked into daily patient safety meetings, monthly clinical governance and the clinical development group which occurred every 6-8 weeks. Information was then shared at regional and board level through monthly regional governance meetings and board meetings. We reviewed the minutes from the clinical governance meetings, these were comprehensive and contained relevant reports for different areas of governance. Patient and staff feedback were represented within the meeting.
• Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. These were investigated and action plans were put in place where changes to the service were needed. For example, following a patient death, managers had undertaken a piece of work to improve the monitoring and support of patients who refused food, fluids or medication.
• Staff undertook or participated in local clinical audits. The audits were mostly sufficient to provide assurance. However, environmental audits did not identify all the issues with the cleanliness and safety of the environment and it was not clear how all blind spots had been mitigated.
• 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 was reviewed at monthly governance meetings. The service had a health and safety committee, which provided oversight of health and safety issues. However, managers had not identified some of the concerns we identified during our inspection. Managers had not identified or mitigated risks to patients being transferred by car for the purposes of seclusion. Staff had not received training to manage the increased risks of patients being restrained whilst in a moving vehicle and guidance did not provide sufficient detail to mitigate these risks. However, seclusion use was low and there had been no instances of staff transferring patients to seclusion via vehicle in the six months prior to inspection.
• Managers had also not identified the risks of staff not receiving a structured and recorded induction when moving staff between wards.
• Managers monitored performance and addressed issues with individual staff members when these were identified.
• Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. The risk register reflected concerns relevant to the service and was updated regularly. Concerns about fire risks were present on the risk register, however the health and safety committee raised concerns about the fire doors and these were not present on the risk register. When we raised this, we were informed this was due to a technical issue and that these concerns were documented on the site improvement plan. Some concerns appear to have been on the risk register for a long time, for example the issues we found with the heating in the building had been on the risk register since 2023.
• The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff.
• Staff did not always have access to the equipment and information technology needed to do their work. The information technology infrastructure, including the internet did not always work well. Staff told us there was not always enough computers available and that that the internet connection was unreliable. IT system failure was on the risk register and an IT business continuity plan and disaster recovery plan were in place. Information governance systems included confidentiality of patient records.
• Team 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.

We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

• Directorate leaders engaged with external stakeholders – such as commissioners social services, and external healthcare providers. Commissioners told us that staff were open and transparent and responsive to feedback and any concerns raised and that managers engaged openly in meetings when further information or assurance was required.
• Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

• Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. A range of innovations were taking place in the service. For example, managers recognised that leave planning was not being used effectively and a project was carried out to improve leave planning and to use itinerary planning more effectively. This included the production of a staff workshop.
• Staff had opportunities to participate in a variety of research. For example, the service was taking part in research looking into the effects of patient bullying within secure services and were also carrying out research relating to bowel health.
• Staff used quality improvement methods and knew how to apply them. For example, following concerns that staff were not always completing physical health monitoring staff led a quality improvement project which involved a in depth review of the issues and causes. Following this, actions were effectively implemented which significantly improved the completion rate of physical health monitoring.
• Staff participated in national audits relevant to the service and learned from them.