UCS Medical

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, based on meeting the needs of patients and the wider community. However, this was not demonstrated. Many staff did not understand how their roles contributed to strategic objectives and reported feeling insufficiently supported or valued. Leadership oversight and engagement were inconsistent, and arrangements for staff feedback, freedom to speak up, and workforce equality were not robust, limiting staff confidence that concerns would be addressed. Opportunities for learning and development were limited.

We also assessed whether managers proactively supported staff and worked collaboratively with partners to deliver care that was safe, integrated, person-centred, and sustainable, and to reduce inequalities. Governance, management, and assurance systems were ineffective in supporting this. Policies were not routinely reviewed, audits were not undertaken, and risks were not consistently identified or mitigated. Roles and accountabilities were unclear, and leaders could not provide assurance that safety, quality, and sustainability were being effectively managed.

This was the first assessment of the service, and the well-led domain is rated as inadequate. This meant patients’ needs were not met through good organisation and delivery of 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.

The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The service had a long-term business strategy which it reviewed quarterly with progress updates and actions and focussed on delivering new services. Staff we spoke with had very little awareness of how their work contributed to achieving the aims and objectives set out within the strategy. However, staff were focused on the needs of patients receiving care and delivering a caring patient experience.

The services core values were displayed for staff to view and on the services website. Staff could not describe the core values but knew where to find them.

Feedback from people who used the service, their families and carers were not always collated or shared.

Staff did not always feel respected, supported and valued. Relationships between staff and managers were not always positive. Staff spoke did refer to teamwork and collaboration amongst their peers and colleagues.

Staff were not kept informed about the future direction of the service and some voiced concern in the absence of this.

Staff told us they were thanked for their work but often not paid on time which caused some conflict with managers.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Managers did not identify the priorities and issues the service faced. Managers were visible, but not always approachable in the service for patients and staff. Staff felt the managers did not support them to develop their skills and take on more senior roles. One manager also undertook patient facing activities to assess for themselves how the service was running.

Incidents were not always reported so staff knew how to deal with concerns when raised. The service did not have a positive culture as staff described lack of learning opportunities and a blame culture in the absence of established processes.

Team meetings were not held regularly, and not all staff were invited to team meetings to ask questions or make suggestions. Staff told us meeting minutes were not always cascaded.

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

The service did not have a Freedom to Speak Up Policy and staff were not sure if there was a designated lead or how to access this. The service did not have a whistleblowing policy outlining the formal process for reporting concerns. Staff told us they would escalate issues directly to external organisations.

Managers told us they acted with openness, honesty and transparency. Staff were encouraged raise concerns and offer ideas; the culture allowed staff to be confident their voices were heard. However, staff told us when they had raised valid concerns these were not investigated and they were not supported without fear of detriment. When concerns were raised, managers had not investigated sensitively and confidentially.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Managers told us they would act to improve where there were any negative experiences for staff with protected equality characteristics. However, managers could not provide any examples of this. Managers told us that staff with disabilities would be offered reasonable adjustments to support them to carry out their roles well. An example of reasonable adjustments made for a staff member to carry on working was provided.

Staff did not have opportunities to apply for project work, new roles and to undertake external studies through an open application process.

Staff felt everyone was treated fairly but not all staff felt that they would be able to report behaviour or attitudes which were negative in style.

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

The service did not operate effective governance. The service had a governance policy that described the governance framework and activities that should take place to support it. The registered manager told us these activities did not take place. Information was not routinely collected, monitored and communicated internally. Performance data was not gathered, analysed and compared within the service and where improvements were needed at the location level, action plans were not developed to make this happen.

Frontline staff were clear about their roles and accountabilities due to undertaking similar roles in other employment. Not all staff had job descriptions setting out expectations and responsibilities.

Staff could not find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements, as it was either in accessible or did not exist.

Risks were not clearly identified and whilst a formal log of these was used to keep oversight and manage mitigations and/or bring to resolution, it was not maintained accurately. Control measures identified in the services risk assessments were not always in place. Staff did not contribute to decision-making to help improve sustainability and improve quality of care.

We requested the services audit schedule and results as part of the data request. The registered manager responded to the request stating that no audits were currently being undertaken in the service due to capacity. There is a risk that the service may not identify issues with the quality or safety of care which places services users at risk of harm.

The service did not have effective systems to assess, monitor and improve the quality and safety of the service. The policies, systems and processes were not tailored to the service.

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

Managers did not engage with local authorities, hospitals and emergency services to plan service delivery and ensure expectations were aligned. The registered manager did not meet with external stakeholders and regional networks.

Managers sought feedback from the referring organisation following transportation of patients, however written evidence of this was not kept or if it was kept was not accessible. Collaboration with other care providers for the patient’s benefit was not included in patient records.

We received feedback from 3 stakeholders about the service provided by UCS Medical. They told us that the service ‘understood the diverse health and care needs of people in local communities’ and that ‘care was joined up, flexible and supported choice and continuity’ and that ‘their approach supports choice and meets diverse requirements effectively’. We did not see evidence of this on assessment.

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

Staff were committed to continually learning and improving services, however there were limited processes or opportunities in place for learning when things went wrong or share good practice.

The service did not have a quality improvement strategy and there were no ongoing quality improvement projects underway.

Staff were not supported to develop their skills around improvement and innovation and to pursue areas of interest in the service. Managers did not encouraged innovation through patient and staff feedback.

Staff and managers were not committed to excellence that centred on the patient experience.