T.H.O.M.A.S

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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 changed to Requires Improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

There was a lack of effective oversight in relation to cleanliness, the environment, implementation of some policies, ensuring staff received all required training, supervision, and regular appraisals, and medicines management in relation to temperature checks.

We found that the environment was not consistently maintained. Some areas and furnishings were not clean and posed safety risks. Cleaning and monitoring practices were not consistently effective.

The service did not have clear governance processes to ensure resident safety through the use of Personal Emergency Evacuation Plans.

However, managers and staff were passionate about the service and the positive impact it had on residents and the wider recovery community and networks.

Stakeholders told us they found the service was effective and responsive, and that they had good working relationships with staff, operationally and strategically.

The service was in breach of Regulation 17 in respect of governance at the service.

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 provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. Staff understood how these were applied in their team’s work and with residents. The service had a clear philosophy that underpinned the structured therapeutic model based on the 12-Steps recovery programme. The service aimed to create and sustain a therapeutic community to support individual residents in their recovery journey. The approach also extended into the wider recovery culture of the locality, supported by the long-term presence of the service in the Salford area.

Staff, partner organisations, and commissioners described the positive impact the service had on resident outcomes. These were summarised and presented in case studies of recovery journeys to commissioners and the service’s contracting organisation. Staff were committed to the recovery model and demonstrated a strong belief in its effectiveness. They spoke confidently about how the structured programme and therapeutic community contributed to sustained change for residents.

We observed group sessions in which all residents participated in recovery-focused discussions and activities. They shared, in supported conversations, the challenges of undertaking the recovery programme, the risks of relapse and its long-term consequences, and the value of honesty and forgiveness within the group.

Leaders had the skills, knowledge and experience to perform their roles. For example, the provider’s chief executive was undertaking doctoral academic research relevant to the service. The chief executive was passionate about the work of THOMAS. They were proud of the standing and impact the service had developed, and how it contributed to the recovery community in the North West region.

Leaders had a good understanding of the services they managed. They explained clearly how the teams were working to provide high-quality care. Leaders were visible in the service and approachable. However, the service’s registered manager had left, and a replacement had not been recruited at the time of the assessment. This meant that oversight of the service was temporarily reduced, with the provider’s senior staff providing interim leadership and support. The provider submitted a registered manager application within 1 month of the on-site assessment.

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

Staff told us that they could raise concerns with the team or senior leaders, and that speaking up was encouraged. The provider had a whistleblowing policy and procedure. There was a formal Freedom to Speak Up role within the service, and staff commented on the open culture, which they felt supported transparency and made it possible to share concerns informally.

A staff survey to gather feedback had not been completed in the 12 months prior to the assessment. We asked the organisation to provide evidence of staff feedback, however the service could not provide direct feedback from staff during this period.

Residents attended a weekly community meeting. These meetings promoted the resident voice within the service. A suggestions box was also available for residents who wished to provide feedback anonymously.

The service had an equal opportunities and diversity policy, and an equalities and diversity scheme. Staff that we spoke to did not raise any concerns about workforce equality, diversity and inclusion.

The registered manager was the named equalities and diversity officer for the service. However, this member of staff had left, and the interim service manager was not named in the relevant section of the equal opportunities and diversity policy. This meant that accountability for promoting and monitoring equality and diversity was not clear at the time of the assessment.

The provider’s equal opportunities and diversity policy outlined the service duty to put reasonable adjustments in place for staff members to help them carry out their role.

The service did not have adequate governance processes to ensure that the service was running effectively and to provide managers with appropriate oversight, monitoring, and assurance.

There were no systems in place to ensure that residents with mobility needs had personal emergency evacuation plans (PEEPs). The service’s buildings risk register incorrectly stated that no residents required assistance in the event of a fire. There was a risk that staff may not have been able to support individuals to evacuate safely. This indicated a lack of oversight and assurance in safety planning. Following feedback during the assessment, the provider took action to develop and implement PEEPs for relevant residents.

We found that the provider’s own monitoring systems had not identified compliance and assurance issues, for example ensuring that Personal Emergency Evacuation Plans (PEEPs) were in place, and compliance with training, supervision, and appraisal requirements.

The provider’s own audit processes did not ensure effective oversight of environmental cleanliness, and they did not undertake consistent environmental and infection and prevention control audits. For example, there was no documented assurance that deep cleaning of the kitchen was being carried out.

The provider did not ensure effective oversight and audit of medicine room cleaning processes. It was not clear from the cleaning records rota how many, or which days, cleaning should have taken place, and there were gaps in the records where tasks had not been initialled. As a result, we were not assured that cleaning had consistently taken place in line with the provider’s policy.

The provider did not have systems in place to ensure temperature checks were recorded for the medicine room or the medicines fridge. This indicated a lack of oversight and audit in monitoring safe storage of medicines.

Governance policies we reviewed were in date and provided comprehensive guidance for staff. The service had policies to guide staff in the day-to-day operation of the service, and to manage risk, for example, a lone worker policy, line management and supervision policy, equalities and diversity scheme, and whistleblowing policy. However, the provider did not have policies for searches, restrictions, or prohibited items, and did not ensure staff were familiar or trained in its lone worker policy. Neither did the provider have oversight of appraisals and supervision in the absence of a registered manager.

There were a range of meetings in place to support the running of the service. There was a clear framework of what must be discussed at team and senior leader meetings to ensure that essential information was shared and discussed.

The service had a risk register tool, which combined a health and safety assessment with risks to the service, residents and staff. It identified several areas of risk such as fire, utility failure, environment, staff and client wellbeing and security.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the residents.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and client care.

Managers told us that performance was monitored by completion of regular audits. We reviewed meeting records where outcomes were recorded and discussed in management meetings.

Staff line management meeting agendas included a standard item for training, learning and development. We reviewed meeting records where learning needs and actions had been discussed and documented.

Staff participated in national audits relevant to the service. We reviewed management meeting minutes that recorded submission to the National Drug Treatment Monitoring System.

Managers engaged well with external stakeholders, such as commissioners and as contracted services. Stakeholders told us that the service consistently met contractual expectations, and stakeholders had confidence in the service’s ability to deliver safe and effective services across the localities and communities it served.

Staff we spoke to could describe a range of partner agencies, external services, and local third sector organisations they collaborated with or referred to, to support residents’ person-centred care. This reflected a well-established approach to collaborative working and demonstrated that staff understood how to access appropriate support to meet individual needs.

Stakeholders told us that the service had developed a network of recovery peers and mentors. This approach incorporated lived experience into the therapeutic community and added value to the support provided to residents. This reflected a commitment to person-centred care and inclusive service development. The provider was a member of the Northwest Rehabilitation Treatment Network.

Voluntary sector organisations spoke positively about working relationships with staff. They told us that communication was effective and that the success of joint projects was due to staff engagement and enthusiasm. This reflected a collaborative approach and a commitment to enhancing the experience of residents through partnership working.

Residents attended local fellowship meetings throughout the duration of the provider 12-week therapeutic programme.

Innovations were taking place in the service. The provider had introduced a new learning programme focused on reflective practice within the rehabilitation service. This approach recognised that “one size does not fit all” and emphasised the need to adapt methods to meet individual needs. The programme aimed to support staff in developing new ways of working with individuals who found it difficult to engage with traditional drug and alcohol recovery approaches, enabling more personalised and effective support strategies. This reflected a proactive approach to workforce development and service improvement.