Hackenthorpe Lodge 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 one 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. Although not long in post, staff expressed confidence in the manager’s ability and knowledge and told us the service was well-led.

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.

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 SARC was compliant with it. Information was disseminated through regular staff bulletins, the provider’s staff intranet and through updated operating procedures.

There was a clear and easily accessible system in place for staff to report any incidents of non-conformance that occurred. All incidents were graded, reviewed and used to drive improvement. For example, following a missed toxicology sample, forensic templates had been updated to include additional prompts for staff. Recurring problems with equipment had led to additional staff training. Information from patient complaints was also analysed with lessons learnt shared to prevent their recurrence, evidence of which we viewed.

There was a strong emphasis on continuous improvement. Inter-SARC comparison exercises had been introduced across all the provider’s sites. Staff were presented with a particular case scenario exercise, and their responses were assessed. Results and takeaway messages from these were shared across staff teams to ensure conformity to protocols and procedures.

A rolling annual audit plan had been developed to assess key areas of performance such as staff training, health and safety, medicines management, and the quality of patient records. Each month the manager conducted audits for infection control, the management of patients who self-referred and medicines prescribing. 10 sets of patient care records were audited for each nurse to ensure recording keeping standards were maintained. In addition to this, there were regular clinical site visits from senior managers to check compliance with various aspects of the service.

All staff received regular supervision, appraisal and peer review to ensure their practice met professional standards and identify 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.’ One nurse told us they had recently received a retail voucher in recognition of coming into work very early in the morning to assist stretched colleagues.

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 greater variety of snacks and for blankets to be placed in waiting areas had been implemented.

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.