Spring Wood Lodge

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

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 requires improvement. The service was in breach of legal regulations in relation to governance processes which focused on record keeping and the auditing of records. The service had made improvements and was no longer in breach of regulation. Records were up-to-date and governance processes supported a culture of learning and improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

Staff we spoke to could described the services approach to caring for patients and the principles guiding it such as person-centred care and least restrictive practice,

Leaders at the hospital could explain how they were working to deliver high quality care within the budgets available. They could also describe how the service was working to engage with staff and promote diversity and inclusion within the service.

Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the services they managed, including how the different wards worked to support patients with different types of needs. They could explain clearly how staff teams were working to provide high quality care.

Leaders were visible in the service and both the patients and staff we spoke with described them as approachable and having an ‘open door’ policy.

Leadership development opportunities were available, and staff told us how they had been supported to develop into leadership roles.

Patients and carers had opportunities to give feedback on the service they received in a variety of formats that reflected different communication needs and preferences. Managers and staff had access to this feedback and used it to make improvements. We saw data on feedback collected by the service on display.

Most staff said they felt able to raise concerns with leadership and said that these would be taken seriously.

Leaders at the hospital worked to develop an inclusive and fair culture for staff within the service. They worked to understand the needs of their staff and provided additional support where necessary to support staff with their work and wellbeing.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings. We saw agendas and minutes from a variety of governance and ward team meetings which demonstrated clear and consistent structures, and ensured that essential information, such as learning from incidents and complaints, was shared and discussed.

Staff had implemented recommendations from reviews of incidents, complaints, and safeguarding alerts at service level. The service used systems to collect data from wards on a variety of topics, including incidents, which was regularly reviewed. Some outcomes data was also reviewed at a service-wide level as part of evaluating the effectiveness of patient care. These reviews aimed to identify patterns and trends which may indicate areas for improvement to the support offered to an individual patient, and areas for possible service-wide improvement. Staff did not report any concerns with the administrative requirements relating to reporting this data.

Staff had access to the equipment and information technology (IT) needed to do their work. The IT infrastructure, including the telephone system, worked well and helped to improve the quality of care. Information governance systems included confidentiality of patient records.

The service had plans for emergencies. For example, adverse weather or fire. Staff were aware of these plans and regularly reviewed the equipment involved in responding to emergencies like these, for example a ‘grab bag’ for evacuations.

External stakeholders, including commissioners, reported regular and effective engagement with the service. Commissioners also told us how when they raised concerns with the service, the service was responsive in addressing them. Stakeholders also told us that information sharing relating to safeguarding and risk management was consistent and the service collaborated well with local authority safeguarding partners.

We saw evidence of continuous learning and improvement during our assessment of the service. Throughout our assessment, staff demonstrated an ability to reflect on their own practice and the approach of the service. The service had conducted multiple recent quality improvement projects which aligned with its goals as a rehabilitation-focused service and were informed by feedback, data, and recent research. A project was underway reviewing how Bronte ward could become more trauma informed in its approach and the service had begun the process to pursue the Triangle of Care accreditation which focuses on their approach to supporting carers.

Staff also told us about how they had developed and delivered staff training on conducting patient observations in collaboration with a service user. Staff said this had a positive impact on how observations were carried out which demonstrated the value of patient involvement in quality improvement initiatives.