InHealth Jarvis Breast Screening Centre

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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 looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment, we rated this key question as 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.

The service was in breach of legal regulation for 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.

Staff and leaders did not always demonstrate a positive, compassionate, listening culture that promoted trust and understanding between them. For example, staff said there were plans to scrap delivery of results by doctors at the service and/or insistence that other clinical staff should be able to inform a patient when their biopsy result confirmed cancer. However, leaders told us the responsibility of cancer biopsy results resided exclusively with the consultant or senior medical practitioner. The current practice involved the radiologist who performed the biopsy, giving them the result, even if that meant a delay and inconvenience to the person. Leaders were keen to change this and allow people to choose to see a consultant surgeon local to them for their results, instead of returning to the service. This was because, sometimes people had to attend the service on one day and see the surgeon on the next. This cost time and money and had an environmental impact because of the distances some had to travel. Leaders said, those diagnosed with mammogram M classification score 1, 2 or 3 cancers will continue to return to the service for their results appointment.

The registered manager had the skills, knowledge and experience to perform their role. The registered manager was not the director of breast screening as anticipated by the commissioners of the service. To cover this aspect of the service, the deputy director of screening had clinical oversight of the service. They were supported by directors of breast screening with input from other clinical directors.

We scored this quality statement as 1. The evidence showed some shortfalls. Staff did not always feel they could speak up and their voices heard.

There was a culture of fear amongst staff, and some felt if they spoke up, they would lose their jobs. Staff mistrusted the leadership, which impacted on their confidence to speak up. One staff told us they felt anxious at work, and they would be dismissed for speaking to the Care Quality Commission (CQC) during our site visit. Some staff were concerned some leaders were attempting to find out which staff member/s reported concerns to CQC and NHS England. They also raised concerns about 2 former colleagues who left the service, because of action taken following them speaking up. However, leaders informed us those staff left for other reasons, which could not be disclosed due to confidentiality.

There was a Freedom to Speak Up policy dated July 2024 and due for review July 2027. There was also Freedom to Speak Up Guardians and diversity champions, but they were either not well known by staff or mistrusted and therefore not approached. Staff did not feel it was safe to raise concerns about quality and safety of the service and felt there was a blame culture. However, leaders told us everyone had a voice and denied there was a blame culture in the service.

Leaders said there were previous allegations of bullying and harassment in the service, before they were in post. These allegations were never followed up as per policy and the current leadership changed that. Leaders said the culture of bullying and harassment would not be tolerated in the service. A staff charter was introduced in March 2023 to remind staff of the service’s values and behaviour towards others. In addition, leaders said staff sickness and annual leave were not being managed properly previously and now that they were and rules were being put in place, staff did not like it.

People and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Managers and staff had access to the feedback from people, carers and staff and used it to make improvements.

Staff could meet with members of the provider’s senior leadership team to give feedback. A meeting with all staff, the registered manager and the chief patient engagement officer, took place the week after our site visit. Feedback from that meeting was mixed. Some staff found it useful, whilst some felt it was not.

We scored this quality statement as 1. The evidence showed significant shortfalls. The service did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Some staff members with a protected characteristic did not always feel welcome in the service. We were told a senior leader was brought to tears because they were not made to feel welcome at an external event by colleagues.

Leaders did not address reports of discrimination based on a protected characteristic in a timely manner. For example, despite staff reports of poor treatment based on race, leaders told us they did not take any proactive action to address this and instead, were waiting to see if the culture changed without their intervention.

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. The registered manager recruited staff from diverse backgrounds.

There was an Equality Diversity and Inclusion strategy and a recent annual report, but we did not see the results of this, as the link submitted was on the provider’s Intranet. The service published its Workforce Race Equality Standard (WRES) reports and Gender Pay Gap reports publicly on its website. The April 2024 report found there were challenges in understanding the true representation of its workforce because 14.5% of staff had not declared their ethnicity. However, there was a need to close the bonus gaps, reduce racial inequity in recruitment, retention, and progression, and ensure equitable pay progression.

We scored this quality statement as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was a clear framework of what must be discussed at team or management meetings, to ensure that essential information, such as learning from incidents and complaints, were shared and discussed. The governance structure chart showed how communication flowed between frontline staff and the provider’s board. There were board sub-committees, and groups on risk and governance, safeguarding, information governance and clinical quality.

There was a clinical governance team that included the chief medical officer and director of clinical quality. Governance meetings took place quarterly, senior management meetings weekly and consultant meetings monthly. There was a service level agreement with NHS England, based on the NHS standard contract, which was monitored through contract monitoring. Leaders participated in governance meetings for the Surrey and North Hampshire Breast Screening Programme with NHS England, where performance, incidents and feedback were reviewed.

Leaders had implemented recommendations from reviews of incidents and complaints. They encouraged staff to report incidents and there was a process for escalation. Reported incidents were allocated to a manager, who investigated them. Safety incidents were investigated and reported to commissioners. Panels were convened in the event of serious incidents but there were no serious incidents in the past 2 years. Incidents were also raised with the clinical governance team.

The service managed risks, issues and performance. The service had a risk register in place which captured the highest risks. Leaders reviewed and monitored the identified risks and created actions to mitigate or remove them. A recent operational risk added to the register was linked to staff shortages in the pathology department of a local trust. The service identified the potential for delay in results which could impact people’s treatment and the service’s KPIs. The service recognised the need to review the concern and establish the workforce to ensure they could provide their service safely. A review date was in place to re-evaluate the concern and had a dedicated leader taking ownership and managing the risk.

Key performance indicators (KPIs) and performance were discussed at senior management meetings and with all staff during 6 weekly audit half days. The list of KPIs for service was seen and the service’s performance report for 2024-25 showed that it met most of its KPIs.

Where cost improvements took place, they did not compromise peoples’ care. Staff had concerns that there were delays to equipment repair because of cost savings. However, there were no reported incidents of poor person care due to lack of equipment. Leaders said they tried to ensure value for money, so changed an equipment maintenance plan from a platinum to standard service, so less money was paid on an annual basis. However, equipment was still repaired as and when required. Leaders said this was communicated at the senior management meeting but were not certain whether it had been disseminated to all staff.

The service used systems to collect data that were not over-burdensome for frontline staff. Since February 2025, mobile screening units had, had electronic connectivity to the static unit. The service planned to re-introduce paper-lite only to the static site as it was put on hold in November 2024. However, there were no current plans for the service to go paper-lite for reading images.

Staff had access to the equipment and information technology needed to do their work. Administration staff booked appointments for people manually online, 6 weeks in advance. Since February 2025, 6 appointment slots were available per week. People had some limited ability to choose and book appointments online. Information governance systems included confidentiality of people’s records.

We scored this quality statement as 2. The evidence showed some shortfalls. The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Leaders did not always collaborate with all relevant external stakeholders. In one example, the service transferred high-risk MRI people from an external provider to the in-house scanner at a local hospital. However, the commissioners were not notified of this service delivery model change until after it had occurred, despite forming part of the service specification and required under General Condition 12 of the NHS Standard Contract. We were told this change occurred at pace to maintain an essential pathway when the previous provider withdrew at short notice.

Staff and leaders engaged with people, communities and partners to share learning with each other that resulted in continuous improvements to the service. Leaders engaged with external stakeholders – such as commissioners. The registered manager had been reviewing the terms of those service level agreements, to ensure their effectiveness.

The service did health promotion with the local community, including GP practices, supermarkets and care homes. This was led by the breast care nurse and had a very good uptake from people. Measures to promote breast screening, such as working with GP practices and undertaking effective evidence-based outreach activities for specific population groups, required dedicated time from staff. The service liaised with community health promotion professionals (such as learning disability teams), to make sure they were aware of what the service offered.

Health inequalities were identified in the service’s annual report of 2022-2023. Health inequalities screening occurred at any point along the screening pathway and was carried out to help identify inequalities and interventions that could improve access and reduce inequalities. The service recognised that health inequalities existed across a range of characteristics or dimensions, including social deprivation, geography and the 9 protected characteristics described in the 2010 Equality Act. However, the service also recognised that it still needed to address inequalities in screening, specifically with wheelchair bound people on mobile units.

We scored this quality statement as 3. The evidence showed a good standard. The service focused on continuous learning and improvement across the organisation and local system. They actively contribute to safe, effective practice.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. The 'Coms in box' was implemented recently, where images were sent electronically. Staff in the mobile units were also recently able to see the National Breast Screening System (NBSS) live. NBSS is an IT system that supports various aspects of the breast screening process, from invitation and booking to recording results and managing follow-up appointments.

The service previously had a high recall rate, but this had improved due to the changes made by the service. Staff told us cases were not being arbitrated, and paper records of people were being destroyed prematurely. However, these had now been resolved as paperwork was now scanned onto an internal computer drive. The service had well-being days for staff, which took place following the 6 weekly audit half days.