The Bridgeway SARC

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

We assessed 1 quality statement under the well-led key question. MHC had a clear governance structure with strong leadership oversight, supported by up-to-date policies, procedures, and regular performance monitoring with partners such as the police and NHSE. Audit activity, supervision and incident reporting were well embedded. There was a culture where staff felt supported and took pride in their work. Patient feedback was proactively sought and acted upon, helping ensure the service continued to meet contractual standards and patient need.

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.

MHC had a clear governance structure with clear responsibilities and accountability for the running of the service. There was a SARC manager who oversaw the daily running of the service as well as seeing patients. Senior leaders within MHC had knowledge and oversight of the SARC through the regular local and regional operational meetings.

There were relevant policies and procedures to support the management of the service which were regularly reviewed and updated as required. However, the service did not have a ligature risk assessment relevant to the premises. The performance of the SARC was scrutinised to ensure that it was meeting contractual requirements as well as responding to the needs of patients and partner agencies. The service met with the police and other partners to review performance and monitor outcomes for patients through the quarterly SARC operational meeting.

NHSE commissioners told us they were happy that the SARC was meeting the required standards and performance, which meant patient health outcomes were good. NHSE confirmed that the SARC provided data and reports when expected and they were of good quality.

There was a programme of audits conducted at the SARC, these covered areas such as training and competency, environmental cleanliness and the quality of patient records. However, audit outcomes were not clear; as compliance was not always recorded and actions were not always followed up. From 01 April 2026 MHC had introduced a range of new audit templates and schedules for the SARC to complete. We reviewed these following the onsite inspection, audit templates now included a compliance score and an action tracking record linked to incident reporting. These changes will enable the provider to effectively monitor progress and drive improvement.

Staff felt confident about reporting incidents and were aware of MHC procedures, and incidents were discussed at team meetings, so learning was shared.

Staff actively sought feedback from patients about their experience of using the service and their suggestions and comments were acted on where possible.

Staff took great pride in their work and felt supported by their managers.

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.