Archived: Swadlincote Station

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

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 newly registered service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

We identified breaches of legal requirements under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, specifically relating to governance and staffing.

Governance systems were insufficient to ensure compliance with legal and professional standards. Patient Group Directions (PGDs) were not appropriately authorised or maintained. The provider did not retain patient records, and there was no evidence of robust staff vetting procedures, including background and qualification checks.

The provider did not have effective systems in place to monitor or support the ongoing training and development needs of staff. The provider failed to ensure that staff possessed the necessary qualifications for their roles. There were no effective systems in place to verify or monitor the qualifications of individuals employed by the service.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed significant shortfalls. The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

Whilst leaders were able to explain the provider’s operational goals and commitment to patient safety, there was no clear evidence of a shared direction or embedded culture across the wider workforce. The absence of direct employment, induction processes, or ongoing engagement with clinical staff meant that the provider could not demonstrate how its values were communicated, upheld, or reflected in practice.

Without oversight of care or procedures to promote a unified approach among subcontracted staff, we were not assured that the provider had a consistent culture of compassion, accountability, and continuous improvement.

The evidence showed significant shortfalls. Leaders did not understand the context in which they delivered care and treatment.

Leaders demonstrated a commitment to improving operational processes and responding to concerns raised during inspection. Due to the lack of oversight of clinical staff the provider had limited influence over the behaviours, values, and practices of those delivering frontline care.

Whilst leaders were responsive and took steps to address specific issues, such as introducing new policies following incidents, there was limited evidence of a proactive approach that promoted compassion, inclusion, and continuous improvement across the wider workforce. The absence of direct oversight, structured engagement with subcontracted staff, and mechanisms to monitor the care delivered meant we could not be assured that leadership values were consistently reflected in service delivery.

The evidence showed significant shortfalls. The provider did not have a formal Freedom to Speak Up policy in place. As operational clinical staff were employed and managed by a subcontractor, the provider had limited oversight of the workforce and did not support staff in raising concerns about safety, conduct, or care delivery.

As there was no structured process to ensure that staff could report issues confidentially and without fear of reprisal we were not assured that the service promoted a culture of openness and honesty.

The evidence showed significant shortfalls. The provider did not demonstrate active promotion of workforce equality, diversity, or inclusion. The provider did not maintain oversight of recruitment practices, staff demographics, or training related to equality and inclusion.

There was no evidence of policies or procedures to support an inclusive working environment or to ensure that staff delivering care reflected and respected the diverse needs of the population served. The absence of direct engagement with the workforce limited the provider’s ability to monitor whether staff were treated fairly, supported equitably, or empowered to challenge discrimination.

We were not assured that the provider was fostering a culture of equality or taking meaningful steps to embed inclusive values within its operations.

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

As referenced throughout this report, the service did not hold patient or staff records at the time of inspection. When concerns were raised with leaders regarding the absence of patient records, they acknowledged that they had not previously recognised this as their responsibility, nor had they considered the associated risks. In response to our feedback, the service developed a data transfer policy and process aimed at ensuring appropriate records are collected going forward.

Routine audits of clinical care were not conducted, resulting in limited clinical oversight. The service did not maintain a formal risk register to track and manage emerging risks. While governance meetings were held and used to discuss incidents and risks, it was not clear how frequently these meetings took place, limiting assurance around the robustness of governance arrangements.

The evidence showed some shortfalls. 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.

The provider demonstrated a commitment to working in partnership with external organisations to support safe and effective care delivery at events. Leaders engaged with event organisers, businesses, and relevant local authority departments during the planning stages of each festival to ensure that medical provision was appropriately coordinated and aligned with wider safety and operational plans.

This approach reflected a willingness to work constructively with stakeholders and supported the integration of the service within the wider event and community context.

The evidence showed significant shortfalls. The provider 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.

The provider demonstrated limited evidence of a structured approach to learning, improvement, or innovation. The provider did not routinely collect patient records or feedback and lacked oversight of clinical care delivered by subcontracted staff. This restricted opportunities to reflect on practice, identify areas for development, or implement changes based on learning.

Whilst leaders responded reactively to specific incidents there was no formal system in place to capture learning from complaints, incidents, or audits. The absence of routine clinical audits and performance monitoring further limited the provider’s ability to evaluate service quality or drive continuous improvement.

There was no evidence of innovation in care delivery, workforce development, or patient engagement. We were not assured the provider was actively seeking to improve or evolve in response to emerging risks, best practice guidance, or patient needs.