Magda

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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 is the first assessment for this service. This key question has been rated Good.

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 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 4. The evidence showed an exceptional standard. The service had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the 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.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. For example, we saw discussions in the team meeting minutes relating to the service improvement plan.

Staff and clients had contributed to the development of a team vision. Surveys had been carried out with both staff and clients which focused on the impact the team wanted to make, what this looked like, what was valued about the service and what improvement could be made. For example, ‘giving clients the best possible chance of recovery’ and ‘wanting the team’s impact to be rooted in empowerment, mutual support and a strong sense of togetherness’. The results from this were developed into a team vision which was aligned with the providers visions and values.

The provider’s vision was related to team objectives, and this was embedded in the appraisal framework that included supervisions, and coaching conversations focusing on values, behaviours and objectives.

Staff could explain how they were working to deliver high quality care within the budgets available.

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. Leaders had a good understanding of the service they managed. They could explain clearly how the teams were working to provide high quality care and there were systems in place to ensure senior management oversight and support.

Leaders were visible in the service and approachable for clients and staff. The executive team and directors carried out carried out half day visits to services on a rota basis and discussed these in governance meetings. Staff spoke highly of leaders at all levels and felt listened to and respected.

Leadership development opportunities were available, including opportunities for staff. Managers could access a range of training including leading with accountability; the leader’s journey course; managing capability and safer recruitment.

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.

Clients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The service carried out regular staff and client surveys and the feedback from these surveys was positive. However, the results were not broken down into individual services which meant it was difficult to identify where improvements needed to be made.

The service had a whistleblowing process in place and staff were aware of this.

Managers and staff had access to the feedback from clients, carers and staff and used it to make improvements. For example, the clients asked for an increase to the food budget and this was agreed.

Clients and carers were involved in decision-making about changes to the service.

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 ‘this is me’ groups within the service including LGBTQ+, ethnic monitories, youth and neuro diversity. These were part of an overarching ‘this is us’ group which focused on equality, diversity and inclusion. Sub-groups managed equality, diversity and inclusion projects which included a yearly calendar of projects and the provider had held an inclusion forum for staff focusing on closing the equality gap.

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 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 client group.

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 team or senior management level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Team meetings included provider updates and updates from manager’s meetings. The service had a governance policy which provided guidance for governance management. The policy included governance principles and a governance framework and provided structure to a range of governance processes such as meetings and policies and processes.

Not all policies in place were comprehensive or reflected the needs of the service. For example, the lone working policy stated that staff had access to lone working devices equipped with GPS tracking, which was monitored 24/7. Staff did not have access to this and carried out a considerable amount of lone working including sleep-ins and transporting clients from detoxification to the rehabilitation unit. The manager said staff used to have this, but this was stopped. However, this was not reflected in the policy and there was insufficient guidance on how staff would manage during an emergency situation. The medicines policy appeared to be incomplete, for example it mentioned controlled drugs that required further documentation but there was no clarification on what the additional record keeping requirements were or how to put this in place should it be required.

Staff had implemented recommendations from incidents and safeguarding alerts at the service level. Learning from incidents and safeguarding concerns across all the rehabilitation services was shared with staff in team meetings.

Staff undertook or participated in local clinical audits. For example, audits of care plans, medicines management and safeguarding had taken place. The audits were mostly sufficient to provide assurance and staff acted on the results when needed. However, the audits did not identify some of the concerns we identified during the inspection, for example, safeguarding concerns were not always being explored and documented and there was not always a clear plan to manage health concerns.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the clients. Stakeholders told us that communication and working relationships were very effective.

The service had a risk register and staff could escalate concerns when required. Staff concerns matched those on the risk register. There were systems in place to manage performance concerns.

The service had plans for emergencies – for example the provider had made plans as to how it would manage a digital attack.

The service used systems to collect data from services that were not over-burdensome for frontline staff.

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 client records.

Managers had access to information to support them with their management role. This included information on the performance of the service, staffing and client care. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

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.

Directorate leaders engaged with external stakeholders – such as commissioners, social services and other community organisations. Leaders engaged with a range of providers to share information about resources and services that benefitted clients and those in the local community who may need the service.

Clients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

Quality Statement Score: 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.

Staff were given the time and support to use opportunities for improvements and innovation and this led to changes. Staff had opportunities to participate in research. For example, staff at the service were involved in research around ketamine use and this led to the creation of a bespoke service meeting the needs of ketamine users. This was shared with other services through articles in journals and speaking at shared events such as a national conference.

The service developed programmes with a focus on evidence-based practice. The service’s group programme was based on research carried out by the psychologist. This was carried with support from a research mentor at a local university. Staff participated in national audits relevant to the service and learned from them.