DrPA Secure - 42 Kew Court

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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 looked at 5 quality statements. We looked at evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

The provider had a structured meeting and risk management framework. They met regularly with Trusts and commissioners to discuss performance, concerns and suggested improvements.

They had developed a clear vision, mission and values - “CARE” Compassion, Assurance, Respect, Empower, which was created collaboratively with staff. Leaders spoke enthusiastically about embedding these values across the service, from recruitment through to induction and their annual appraisals. The organisation had also achieved recognition as a Disability Confident employer and received the Lived Experience Charter award.

Although not all learning processes were yet fully embedded, leaders provided examples where quality issues had been identified and addressed through effective partnership working with the Trusts. However, they were unable to demonstrate how lessons learned from incidents, audits or quality improvement activities were shared consistently with all clinical staff or embedded across staff groups.

The leadership team acknowledged that their business strategy required formalisation. However, they had recently undertaken a comprehensive clinical service review. This looked at the structural, governance, and operational changes needed to ensure safe, sustainable, and compliant healthcare delivery across all settings. We saw they had developed a phased improvement plan towards the proposed future model, demonstrating they had identified and considered several of the improvement areas highlighted during our assessment.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their staff and organisation. Leaders had the skills, knowledge, experience to lead effectively. They did so with integrity, openness and honesty.

There was an overarching clinical governance policy that set out the principles of clinical governance and the expectations within the service. There was a revised clinical audit plan, and we saw evidence of completed audit cycles.

The leadership team had a comprehensive understanding about the challenges in GP provision in secure settings, with a view to improve patient care and access. This included ongoing collaborative work with its partners.

Staff told us leaders were contactable when needed and responded to any concerns raised. Evidence demonstrated the provider engaged in the development of primary care services in conjunction with its secure estate partners.

The leadership team described promoting openness and psychological safety, supported by an independent whistleblowing service. They told us that all staff were encouraged to ask questions, challenge ways of working and make suggestions for improvement. They had plans to improve proactive engagement with staff and to develop methods to gather feedback from staff, including surveys and their GP portal. Feedback we reviewed from staff confirmed they felt comfortable raising concerns and found leaders approachable.

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

At the time of this inspection, the management team had clear responsibilities, roles and systems of accountability to support good governance. From the evidence collected at this inspection, it was clear the management team delivered good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with partners when appropriate.

There was a clinical audit plan in place, which was reviewed on a quarterly basis. Changes and improvements made because of these audits were documented and their effect monitored. The provider gave examples of improvements implemented as a result.

Due to the nature of the business, leaders did not always meet with staff on a regular basis to complete appraisals, performance reviews and clinical supervision. Leaders were improving their GP portal to allow access to all required policies and procedures. Various meetings were held with staff, and partners during which they discussed clinical concerns, emerging risks and performance. Actions arising from these meetings were recorded and shared with staff.

Currently the provider explained they did not collect direct patient feedback. Feedback was shared via its partners through their patient feedback collection. Any feedback gained was collated and reviewed.

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

The service demonstrated an engaged and collaborative relationship with its partners. They spoke positively about the opportunities to build a shared understanding of challenges across the secure estate and in supporting each other to deliver services to meet those needs.

The service worked within a multi-disciplinary team to provide the right support for patients. The service actively participated in regular meetings where people’s care and treatment needs were discussed to improve their outcomes. There was a focus on continuous learning and improvement within the service.