The Elms

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 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.

There were clear lines of responsibility and accountability within the service. A dedicated manager had overall responsibility for the day-to-day running of the SARC and for ensuring compliance with operational protocols. They were supported by an associate head of healthcare and a regional contracts director, both of whom provided oversight and visited the service regularly.

A comprehensive range of policies and procedures were tailored to the needs of the SARC and were subject to regular review and update. All organisational policies were accessible to staff via the provider’s intranet system.

Systems were in place to ensure staff remained up to date with current evidence-based practice. Faculty of Forensic and Legal Medicine (FFLM) guidance was reviewed every six months by senior clinical managers to ensure ongoing compliance. Updates were 6 through staff bulletins, the provider’s intranet, and revised standard operating procedures.

The service had a comprehensive governance framework in place to support learning, oversight and continuous quality improvement. This included regular staff supervision, local team meetings, and daily case review meetings. There were additional structured forums to review performance and manage risk. These included quarterly Clinical Governance Board (CQGB) meetings, regional quarterly meetings, local partnership meetings and weekly regional managers’ meetings.

A joint visit by NHS and police commissioners found the SARC to be compliant with all commissioned service requirements and no recommendations had been made following this visit. Commissioners described the service as responsive and transparent, with effective partnership working arrangements in place.

A rolling annual audit plan had been developed to assess key areas of performance, and we viewed daily, weekly and monthly check lists in use to ensure essential tasks were completed. Risks relating to the SARC were identified, recorded, and managed through a service risk register. This was reviewed and updated regularly by the SARC manager and regional management team.

There was a clear and accessible system for reporting adverse events and incidents, and reporting levels were good. Managers told us that the daily case reviews had been essential in identifying areas of non-compliance that could then be addressed and used to drive improvement

The service had clear arrangements in place to support staff to achieve and maintain the required practice standards. Managers used the competency framework effectively to maintain oversight of staff skills, performance and development needs, ensuring patient safety was not compromised.

The provider demonstrated a strong commitment to staff wellbeing. Regular wellbeing surveys were undertaken, and wellbeing ambassadors were appointed across each region. Staff also had access to trained mental health first aiders, trauma informed practitioners, and counselling services.

Staff told us the service was well-led citing strong teamwork, visible leadership, meaningful appraisals, and effective management. Staff felt appreciated, with recognition schemes such as staff awards in place. One staff member reported feeling valued after receiving an award for supporting service delivery by attending early to cover staffing shortages.

The service actively sought feedback to support continuous improvement. Feedback was requested from patients, their carers, and police colleagues through paper forms and QR codes available on the provider’s website, posters, and leaflets. At the time of inspection, response rates were low, which the provider attributed to the recent reopening of the SARC following a long period of refurbishment.

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.