Casa Suite SARC

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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 assessed 1 quality statement under the well-led key question. Governance systems were good and ensured patients received a safe, well managed and effective service. There was a focus on continuous improvement and staff were supported in their work.

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.

The provider had a clear governance structure in place which showed lines of responsibility and accountability for the service. There was a dedicated manager responsible for ensuring the smooth running of the SARC and compliance with protocols. She was well supported by an associate head of healthcare and a regional contracts director.

Comprehensive policies, procedures and risk assessments to support the management of the service were available and updated regularly. The provider’s clinical quality governance board scrutinised data from across all their services to ensure good oversight of the quality and safety of patient care.

Feedback from NHS commissioners was positive and they told us the SARC was meeting all performance indicators and timescales. They stated staff were always very responsive to their requests and submitted good quality information about the service.

The provider had systems to keep staff up to date with current evidence-based practice. Guidance from the FFLM was reviewed every 6 months by senior clinical managers to ensure the service was compliant with it. Information was disseminated through regular staff bulletins and the provider’s staff intranet. At the time of our inspection, all the provider’s operating procedures were being updated to ensure they met ISO accreditation standards. All staff were actively involved in reviewing these standards to ensure their feedback was considered and to check their understanding of them.

There was a clear and easily accessible system in place for staff to report any incidents and areas of non-conformance that occurred. We reviewed the incidents reported in the 6 months prior to our inspection and found that staff reported a wide range. The associate head of healthcare reviewed all incidents each month to identify common themes and provided us with many examples of where learning had been implemented to drive improvement.

A rolling annual audit plan had been developed to assess areas of performance such as staff training, ligature risk, and medicines management. Ten sets of patient care records were audited for each nurse to ensure record keeping standards were maintained. During our inspection we were shown a new comprehensive site visit audit that was completed by senior managers. This covered multiple areas including patient feedback, complaints management, incident reporting, and health and safety, ensuring key aspects of the service delivery were monitored closely.

All staff received regular supervision, appraisal and peer review to ensure their practice met professional standards and identified any training needs. A compliance report was generated each month by the provider’s governance team, showing which staff were due their supervisions so that none were missed. The provider had recently implemented a staff award to recognise those who had gone ‘above and beyond.’ Staff reported that these awards helped them feel valued and their contribution recognised.

Staff well-being was taken seriously by the provider. There were specific well-being champions and staff had access to trained mental health first aiders, and external counselling support. There was a well-being hub on the provider’s intranet site and a dedicated well-being budget for teams to access. The manager told us that to improve staff well-being locally, the team had started to have breaks outside in good weather and a pottery painting session had been organised to promote team building.

There was a staff council where representatives could liaise with members of the board, ensuring staff views were considered in decision making processes.

Feedback to improve the service was actively sought from patients. Feedback forms were available on site and QR codes were available on the provider’s website, posters and leaflets. Patients’ suggestions to have a phone charger available and seating outside had been implemented, demonstrating the service listened to its patients.

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.