Archived: Solutions 4 Health- Newcastle

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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 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.

The service was in breach of regulation for good governance.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a clear shared vision, strategy and open culture which was based on transparency which was reflected across the entire service. Staff were not aware of the vision and values of the organisation.

Staff at the service did not feel valued by the senior leaders in the organisation and raised concerns regarding the culture fostered by these senior leaders. Staff reported to us an oppressive and bullying culture when senior leaders visited the service. Staff spoke highly of the head of operations.

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

The registered manager for the service was not visible at the service. Staff informed us they very rarely saw the registered manager. The registered manager failed to demonstrate effective oversight of the service had delegated their responsibilities to others.

Staff informed us they only saw senior leadership at the service when there were concerns raised by external organisations. When they did attend the service, staff reported an oppressive and bullying culture.

Ongoing conflicts with the staff and the senior leadership team demonstrated that the senior leaders had a closed culture. Leaders were not able to demonstrate how this conflict would be resolved.

The service had a speak up/whistleblowing policy. However, staff we spoke with did not feel confident that their concerns would be dealt with in an effective way.

Staff at the service had collectively contacted the Local Authority with their concerns about the service, due to a lack of action by the senior leaders.

Staff and managers had access to feedback from service users who accessed the service.

The service did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Some staff were not always supported by the service, a staff member was not always able to join meetings or go up to the staff office due to the lack of accessibility in the building. Staff told us they did not feel the senior leaders have been understanding or supportive when extra support or adaptations where needed.

The service did not have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support.

The service did not have a schedule of audits in place at the time of our inspection. Staff had shared concerns regarding the use of chaperones at the service, we requested the senior leaders perform an audit of service user records. The service was not immediately able to perform this audit and had to request the notes from their system provider to do this. Therefore, we were not assured that the service is conducting suitable audits.

Governance processes at the service were not fully embedded, although the organisation had been providing the service since 2024. A clinical development group had only just been established in June 2025.

The service had failed to provide the relevant safety equipment for staff at the service, although portable alarms were available in each clinic room, they were not regularly checked and tested.

The service had a risk register, however at the time of the inspection the document was not up to date as review dates for some risks had passed. The items on the risk register did not match the concerns of staff at the service or our findings at this inspection. Staff informed us the senior leaders had failed to act on concerns raised by staff, the staff therefore addressed these concerns to the Local Authority.

The service had failed to provide sufficient safeguarding oversight for the service, along with not meeting their statutory duty of notifying safeguarding incidents to CQC.

The service had failed to address confidentiality in the clinic rooms. The walls of the clinic rooms where thin and conversations could be heard through them. The staff were using radios to help block the sound.

Managers at the service did not have access to all the information they required to manage the service. This included a lack of financial oversight such as staffing budgets.

The service was not delivering the level of care that was commissioned by the local authority. Psychosexual therapy was not being delivered by the service.

External partners and stakeholders had raised concerns with CQC and the local authority about the service

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

Staff at the service were not supported to participate in research and pursue opportunities for improvement and innovation.

At the time of the inspection the service was planning to move to a different building which would increase the number of clinic rooms available at the service. The management of the service advised that the move would resolve infection prevention control issues identified by an external audit.