Hartlepool MRI Unit

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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of patients who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant that patients’ needs were met through good organisation and delivery.

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.

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 had a clear vision and a strategy for what it wanted to achieve and to turn this into action.

Staff were focussed on the needs of the patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. This was evidenced by the number of senior radiographers and managers we met who had started as graduates and progressed through the grades in the service.

The service had an open culture, where patients, their families and carers as well as staff could raise concerns without fear. Staff told us they felt respected, supported and valued. Relationships between staff of all grades were positive with strong teamwork and collaboration.

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 a range of experience, qualifications, skills and abilities which enabled them to run the service effectively. Local leaders were visible and approachable in the service for patients and staff. Staff felt that leaders supported them to develop their skills and take on more senior roles.

We saw examples of meeting minutes, where incidents had been discussed with staff with actions to reduce the risk of recurrence. We also saw action plans to address the areas which had scored lowest in the staff survey and a suggestions box for staff was introduced, at the request of staff.

Managers told us that they had sufficient time for their management duties and were supported with weekly meetings with other managers. There was also good succession planning through staff training.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns and offer ideas. The culture allowed staff to be confident that their voices were heard.

Staff told us that they knew how to raise concerns and were confident that any concerns raised would be investigated appropriately and confidentially.

Patients told us that they were not sure how to make a complaint, but they felt sure that if they did complain, the complaint would be taken seriously. Leaflets were available in the department informing patients about how to complain.

There was a freedom to speak up policy, which was in date and the provider had Freedom to Speak Up champions, which were available via the provider’s intranet.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Leaders made sure that there was equality of opportunity and experience for the workforce within their place of work. Staff told us that they had opportunities to apply for new roles and to undertake external studies through an open application process.

The ‘team, inclusion and ways of working’ section of the staff survey scored 4.1 out of 6, which was the highest scoring section of the survey. Staff we spoke with told us they felt everyone was treated fairly and that they felt able to report behaviours or attitudes, which did not conform to the provider’s values.

Staff with disabilities were offered reasonable adjustments to support them to carry out their roles well. For example, where staff were unable to drive due to ill-health, they were allowed to be based permanently at one site rather than working cross-site. Managers also told us about examples of ergonomic adjustments being made to work furniture to accommodate staff with health concerns.

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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The service operated effective governance processes through various committees and meetings. For example, there were weekly quality and risk meetings with the unit manager and operational delivery managers to discuss incidents, complaints, internal audits and any externally reportable events, to share best practice and make improvements across the organisation. There was a clear governance structure within the organisation, with dedicated clinical governance committees and information governance and security committees and subcommittees, which all reported to the board.

Performance data was analysed and compared with the provider organisation. We saw examples of quality and risk reports, where this comparison data was provided. This allowed services to benchmark performance across a range of indicators and develop local action plans if improvements were needed.

Staff at all levels were clear about their roles and responsibilities. Staff had job descriptions and these set out expectations. Staff could find the data they needed to understand performance and make decisions. The information systems were secure.

Leaders made sure that accurate information was discussed and shared with key staff. For example, information was shared via email, messaging apps and team meetings.

Risks were clearly identified and a formal log of these was used to keep oversight and manage mitigations. We saw a copy of the risk register, which included actions taken to reduce risks where possible.

Audit processes and the outcomes were used to ensure quality of services was maintained and improved where possible.

We saw a business continuity plan, which outlined steps to take in the event of system failures, or major incidents such as fire or bomb threats.

We reviewed 19 provider policies and found that these were up to date, and readily available to staff. There was leadership oversight of the accuracy and validity of each policy, with clear review dates and version control.

The service had not reported any data breaches and systems were secure. Patient identifiable information was handled correctly.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff and leaders at the service collaborated with relevant external stakeholders and agencies to improve care and treatment for patients using the service. For example, we heard from stakeholders that the service and trust partners shared good cases for learning with each other and constructive feedback was shared with staff following joint audits. We also heard from managers how the service worked with different sites across the host trust to help reduce waiting times for patients. We saw evidence that service leaders attended regional meetings with other lead radiographers to share good practice and learning.

Leaders and staff actively engaged with patients, the public and local organisations to plan and manage services.

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 contributed to safe, effective practice and research.

Staff were committed to continually learning and improving services. The service provided a full day of continuous professional development activity for staff, which ran twice each year so that all staff had the opportunity to attend.

There were processes in place for learning from good practice, or when things went wrong. For example, there were biweekly quality risk meetings with the regional head of quality for the provider organisation where incidents were discussed. Newsletters were used to disseminate learning from these meetings.

Staff we spoke with said that they were actively supported to undertake additional training or courses, with both time and funding. The service also supported and encouraged staff to be involved in research, and we saw evidence of staff publications and presentations. Managers told us that staff were supported to pursue areas of interest in the service and were given the opportunity to develop skills to develop these interests. Training needs and interests were discussed twice yearly as part of the structured appraisal process.