Emerald Place Clinic

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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 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. The majority of 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 the data 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.

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 we spoke to reported that they felt valued and supported to perform in their roles.

Staff reported that they felt that there was transparency in the service and that the leadership team was visible on the ward. Staff spoke favorably about working for the service with staff reporting that they felt that team worked well together.

The service values were Kindness, Integrity, Teamwork and Excellence, KITE. The most recent staff survey, collated at the end of 2025, highlighted that the KITE values were well implemented and practiced. Staff also fed back that they felt the leadership team were strong, visible and committed to their strategy.

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 organisations. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

We spoke with leaders at the service and found that they had the relevant skills, knowledge and experience to perform in their roles.

Leaders have a good understanding of the service that they managed. They were able to explain to us how the service was performing, areas of improvement and what process were in place to ensure that they delivered high quality care.

Staff informed us that the leaders were visible and that they have an open door policy where staff can access them as required. There was a clear link between clinical management and strategic management of the service. Staff also reported that managers often come in early and stay late to ensure that there is effective communication with all members of the team. Leaders were up to date with current best practice guidance and ensured that relevant knowledge and updates were shared with the team.

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.

We spoke to staff at the service and the majority of them knew how they could raise a concern and many of them felt able to do so. Some staff told us that there was a positive and open culture and that they could approach leaders if there were any issues. Staff told us that there was a Freedom To Speak Up Guardian in place and that they support staff when concerns have been raised. This was reflected in the staff survey results from December 2025. The senior leaders of the service had a rota where managers take it in turn to visit the ward and touch base with staff.

However, some staff we spoke with felt that they were unable to raise their concerns and felt that the leadership team were not approachable.

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.

Staff we spoke with felt that the leadership team were respectful to the team and of cultural diversity. We saw evidence of leaders ensuring that staff from different faith backgrounds were supported during religious festivals and events.

The organisations had 6 employee resource groups; Race and Ethnicity, Neurodiversity, LGBTQ+, Disability, Women and Working Families and Caregivers. The networks were available to all employees.

Staff could receive support from managers through supervision and team meetings.

The evidence showed an exceptional standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service had regular team meetings and governance meetings which all staff were invited to attend.

The leadership team carried out audits and reviews, which they discussed within appropriate forums.

The service had embedded a culture of learning. They developed a programme to “Keep Incident Lessons Learned Alive” and had the actions on display in the lounge area for the young people to read and comment on. The service had a monthly “Incident Analysis Report Meeting” which was attended by the MDT; the meeting identified themes and trends from incident reporting. Conclusions and action plans were created as a result of the analysis.

The service undertook significant changes to service provision in line with previous concerns raised and action plans were created to address the issues identified. For example, the service previously had a significant number of incidents with young people being able to climb on to the roof. Remedial work to the building was completed to prevent this from happening again.

The service was peer reviewed by the Quality Network for Inpatient CAMHS. This is a quality improvement and accreditation network run by the Royal College of Psychiatrists. The service was accredited Sustainable Mental Health Service Commendation in January 2026 in recognition of their work toward achieving a sustainable mental health service and meeting 100% of the CCQI sustainability standard. There service had met the required standard to be fully accredited by the Network.

Staff told us that when incidents occur, the learning is shared with the team. When an incident occurs, debriefs are held with the team in a timely manner.

The audits that were undertaken provided the service with assurances. The results of audits were shared with the teams and the wider service. For example, the service successfully utilised

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.

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.

Leaders told us that they had strong working relationships with local authorities and partner agencies. External stakeholders conducted reviews of the service.

We reviewed feedback from the provider collaborative. The feedback highlighted the positivity of staff and that leaders led by example.

Feedback from carers and families also praised the staff and senior managers for their efforts to support them and their loved ones.

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.

The service was peer reviewed by the Quality Network for Inpatient CAMHS and met all the required standards for accreditation.

The service had undertaken Quality Improvement projects with the participation of the young people and staff. For example, the service ran a QI project to support young people with improved sleep hygiene by altering the evening routine on the ward. The feedback from the project was positive, with young people reporting that the project had been helpful.

The senior leaders also supported the MDT to adapt a community model for the treatment for obsessive compulsive disorder for inpatient CAMHS. The intervention had been successful and other services within the organisation had implemented the model.