The Solace SARC - Bicester

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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

We assessed 1 quality statement under the well-led key question. Governance systems were good and ensured patients received a safe, well managed and effective service. There was a focus on continuous improvement and staff were supported in their work.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

The provider had a national governance framework in place which included policies, protocols and procedures that were accessible to all staff members on the organisation’s intranet site. The provider’s clinical quality governance board met regularly to scrutinise data from across all their services to ensure good oversight of the quality and safety of patient care.

There were clear lines of responsibility and accountability for the service. A dedicated manager was responsible for ensuring the smooth daily running of the SARC and compliance with protocols. An associate head of healthcare, operations manager and a regional contracts director supported them in this work.

There was a clear and easily accessible system in place for staff to report any adverse events or non-conformance incidents that occurred. All incidents were reviewed and graded by the governance team and used to drive improvement, with higher grade incidents reviewed every 2 weeks. A ‘lessons learnt’ meeting, facilitated by the governance team was held every month. Staff were able to give us specific examples of where procedures had been changed because of incidents that had occurred.

There was a strong emphasis on continuous improvement. Inter-SARC comparison exercises had been introduced across all the provider’s sites. Staff were presented with a particular case scenario exercise, and their responses were assessed. Results and takeaway messages from these were shared across staff teams to ensure conformity to protocols and procedures.

A rolling yearly audit plan had been developed to assess key areas of performance such as staff training, health and safety, medicines management, and the quality of patient records. Each month the manager conducted audits for infection control, the management of patients who self-referred and medicines prescribing. 10 sets of patient care records were audited for clinician to ensure recording keeping standards were maintained. In addition to this, there were regular clinical site visits from senior managers to check compliance with various aspects of the service.

Daily and weekly checklists were used by staff to ensure essential tasks were completed on site.

The provider had systems to keep staff up to date with current evidence-based practice. Guidance from the FFLM was reviewed every 6 months by senior clinical managers to ensure the SARC was compliant with it. Information was disseminated through regular staff bulletins, the provider’s staff intranet and through updated operating procedures.

The service had established good working relations with local organisations such as police, NHS Commissioners, social services and local counselling services and held regular meetings where any concerns could be addressed. There were also quarterly partnership board meetings where performance was monitored.

All staff received regular supervision, appraisal and peer review to ensure their practice met professional standards and identify any training needs. A compliance report was generated each month by the provider’s governance team, showing which staff were due their supervisions so that none were missed.

It was clear that staff welfare was taken seriously by the provider. At the time of our inspection, the provider was awaiting the results of a national staff well-being survey it had commissioned

to assess its performance in this area. There were also staff well-being champions and staff had access to trained mental health first aiders.

The provider had recently implemented an award to recognise staff who had gone ‘above and beyond.’ One staff member told us they had appeared on the ‘we celebrate you’ section off the staff intranet site, where positive feedback about their performance had been displayed by a colleague. A new LGBTQ plus network page had been implemented on the staff intranet site demonstrating the provider’s commitment in creating an inclusive and supportive work environment.

Feedback to improve the service was actively sought from patients. Feedback forms were on site and QR codes were available on the provider’s website, posters and leaflets. Patients’ suggestions to have a TV in the waiting room and for additional heating had been considered by staff.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.