Ellern Mede Ridgeway

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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 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.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Posters outlining Ellern Mede’s values were displayed throughout the hospital and were part of mandatory training, which 100% of staff had completed. Staff appraisals were linked to the values, for example teamwork and patient-centred care. Staff we spoke with said they were proud to work for the provider and worked together well to personalise care and meet individual needs. Staff were committed to delivering high quality care.

Young people could become involved in developing the service through community and patient co-production meetings, and carers could do this through family governance meetings. The provider had a patient inclusion lead and expert by experience working with young people and staff. Patients, carers and staff participated in the 15 Steps Challenge, an initiative originally developed by the NHS to evaluate and improve healthcare settings using different people’s perspectives.

However, not all staff felt they had the opportunity to contribute to discussions about the strategy for the service, especially when it was changing. Some staff we spoke with reported low morale and anxiety about job security due to the recent low occupancy at the hospital. They told us they wanted better communication about future direction and more support from senior managers.

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

Managers had the skills, knowledge and experience to perform their roles and a good understanding of the service they managed.

Most staff we spoke with described the managers as very supportive, visible and approachable. Carers said they could contact managers when needed, and one young person told us they were confident to talk to the ward manager who would solve problems.

Training and development opportunities were available for staff. Several managers we spoke with had progressed to their current roles after working for the provider since qualifying.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Carers we spoke with knew how to complain if needed, and said there were regular opportunities to give feedback, for example through weekly feedback forms. Young people could raise queries or concerns at weekly community meetings, although we heard that not all young people attended those regularly. The service conducted annual patient and carer surveys. Patients could become involved in decision-making about the service through co-production meetings, and carers through family governance meetings.

Managers monitored feedback and complaints received. Staff discussed learning and themes identified from feedback and complaints. ‘You said, we did’ feedback was displayed on the ward information boards.

Most staff said they would be comfortable to raise concerns with the managers, if needed. All staff had completed the speak up training. Posters with Freedom to Speak Up information were clearly displayed. However, some staff expressed reservations about approaching the provider’s Freedom to Speak Up Guardian with their concerns.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

All staff had completed mandatory training in equality, diversity and inclusion (EDI). Staff we spoke with thought that the service was open and inclusive for diverse groups of people, with equal opportunities for training and development available. Staff did not raise any concerns about discrimination.

Staff were able to apply to work flexibly to account for personal circumstances, such as caring responsibilities or health issues. Managers put reasonable adjustments in place for staff if needed.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The service had robust governance arrangements in place that supported care delivery effectively. There was a clear framework of what must be discussed in meetings at a ward, hospital and provider level to ensure that essential information was shared. Lessons learnt, both within the provider group and external, were shared and discussed. Staff had implemented recommendations from reviews of incidents and complaints.

Staff undertook local audits and participated in the provider’s comprehensive audit programme. The audits provided assurance and staff acted on the results.

Managers maintained a risk register which detailed an appropriate range of risks specific to the hospital and reviewed it monthly. The service had a robust plan to ensure its activities could continue in the event of emergency, such as severe weather or loss of utilities.

Information governance systems ensured confidentiality of patient records and over 97% of staff had completed training in data protection and cybersecurity. Staff had access to appropriate equipment and information technology needed to do their work. Managers had easy access to information to support them with their roles, such as data on staffing and risk.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. They shared information and learning with partners and collaborated for improvement.

Managers worked with external stakeholders effectively, including regulatory bodies, commissioners, local authorities and key system partners within the local provider collaborative. The service submitted appropriate notifications to the relevant external bodies.

We received feedback from key partner agencies who regularly worked with the service. The stakeholders’ feedback was very positive. They described the service as open and keen to develop in response to feedback. They told us about good working relationships and joint work, for example in reducing restrictive practices and length of stay, research projects and adapting provision for neurodivergent patients. Ellern Mede staff worked closely with system partners when providing complex care.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for patients. They actively contributed to safe, effective practice and research.

Staff had opportunities to participate in research and quality improvement (QI) initiatives. For example, we heard about a joint research project involving Ellern Mede’s lead psychologist and a local CAMHS community eating disorder service. Staff received training in QI. Recent QI projects included reducing restrictive practices, and a new project was planned on reducing nasogastric feeding.

Psychology team told us about initiatives to improve patient and staff experience they planned across the provider group, including improving post-incident support and group mediation.

The service was a member of QNIC (Royal College of Psychiatrists’ Quality Network for Inpatient CAMHS), which focuses on benchmarking and quality improvement in services. Staff participated in the network’s meetings and acted as peer reviewers.