Lombard House

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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.

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

At our last assessment we rated well-led as good. At this assessment, the rating has remained good. 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 analysed data about outcomes and performance. They used this to identify improvements.

The service was in breach of Regulation 12 Safe Care and Treatment.

2(e) ensuring that the equipment used by the service provider for providing care or treatment to a service user is safe for such use and is used in a safe way.

2(g) the proper and safe management of medicines

However, leaders took immediate actions to mitigate these breaches.

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.

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.

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. Leaders told us there had recently been a refresh of the values and patients and staff had been involved.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff attended monthly team meetings where they had an opportunity to discuss any new initiatives the hospital introduced.

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.

3. 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. The provider ensured that staff were trained in working with people with learning disabilities and autism. Learning disability nurses were part of the team.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams worked to provide high quality care.

Leaders were visible in the service and approachable for patients and staff. Staff told us the leaders regularly visit the service and knew the staff and patients well.

Leadership development opportunities were available, including opportunities for staff.

We create a positive culture where people feel that they can speak up and that their voice will be heard.

3. 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.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Carers and patients had the opportunity to complete an annual survey. Where required, patients were supported by independent staff to complete the survey. There is a whistle blowing policy, freedom to speak up guardian and a ‘your say champion’ for staff to raise concerns. Staff had a ‘you say’ meeting once a month where champions came together to share themes.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Staff used a carers newsletter to feedback on improvements to the service.

Patients had regular community meetings where they could raise concerns and offer suggestions. Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback.

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.

3. 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.

There were equality and diversity champions within the hospital. 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. Managers put reasonable adjustments in place for staff members. Staff were able to adjust their hours. For example, if they had childcare responsibilities or a physical disability they could reduce the length of staff shifts. Staff had access to counselling and mental health first aiders.

We 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.

3. 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.

There was a clear framework of what must be discussed at a ward, team, or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. Leaders told us that they had identified concerns with medication and had programmed in an in-depth audit in this area. While we were on site, we found a breach in the emergency equipment which was alerted to leaders who took immediate steps to mitigate these concerns.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register. Staff had identified the step leading to the kitchen as a concern as we also identified on this assessment, this was on the risk register waiting to be actioned. However, it had been not actioned promptly as there had been other maintenance works at the hospital that were prioritised.

The service had plans for emergencies – for example, adverse weather or a flu outbreak.

Where cost improvements were taking place, they did not compromise patient care. Maintenance works were on going while we were on site, patients were supported to access the garden with staff while works were taking place.

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. Team managers had access to information and dashboards 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.

3. 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.

The hospital had a strong focus on maintaining links for patients in the community. Local GP practices, voluntary and community organisations supported patients with their health, wellbeing, work opportunities and to enjoy local facilities and services.

Directorate leaders engaged with external stakeholders such as commissioners. Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

The local commissioning teams had given compliments to the hospital on the joint working in local meetings.

The hospital worked in close partnership with other providers ensuring there was a good transition for patients, when moving on from the service into more independent living arrangements.

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.

3. 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.

Quality improvements took place in the service. The service had updated a local procedure for issuing medication from the clinic room to help minimise distractions. Leaders had a quality improvement (QI) commitment to enable QI change agents protected time per month to undertake their training and to meet and support their projects.

Staff participated in national audits relevant to the service and learned from them. Staff collaborated with patients to create a family and friend’s booklet. Leaders produced an annual audit using patients’ participation. The hospital was part of the national recovery network, using patients in an advocacy role, and as policy reviewers to proofread documents and provide feedback to the hospital.