Archived: ION Pinewood

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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

Leaders were visible and supportive to help staff develop in their roles. There was a culture of continuous improvement and learning with staff undertaking regular training. Not all managers showed a good understanding of the use of systems and processes to manage governance. However, other managers showed support was available to peers. There was an awareness of the need to strengthen and improve the site, which the provider was focused on. Staff felt supported to give feedback and were treated fairly. Staff understood their roles and responsibilities.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has remained the same.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff we spoke with felt supported by the leadership team and understood the service vision to expand in the future. Staff felt happy in their roles and understood they could go to leaders with questions and concerns if they had any. We saw senior managers contacting staff in a friendly and open manner; staff told us they were comfortable speaking with leaders.

One manager we spoke with lacked clinical oversight, the person did not adequately demonstrate oversight of clinical audits, document reviews and errors escalated. They did not appear to be fully aware of the frontline clinical service and reported that the NHS service they had a contract with organised these. The manager was helping to develop the service, whilst monitoring it. The managers recognised this role was too complex for one person and was looking to find support for the individual, but there currently was none. Team leaders worked together and supported each other where possible.

Leaders had plans to develop the site and were undertaking active recruitment for more staff. The organisation had a structured and rotational on-call system in place to ensure appropriate escalation to a manager was available for operational staff. Team leaders were known as team mentors to support the approach of being an organisation of learning and support. Managers had general oversight of concerns raised through complaints and used an online system to appropriately manage these. This system was demonstrated to us during our assessment.

Staff were able to raise concerns to leaders. There was not a specific freedom to speak up guardian, however, staff were aware of means by which they could raise concerns and whistle-blow. It was reported that a freedom to speak up guardian position was being reviewed, another manager told us the position was forthcoming.

There were multiple channels by which staff could raise concerns, this could be in-person with a manager, via online systems to protect anonymity, or by the staff forum. Staff raised concerns at a team meeting, their concerns were addressed and responded to in a newsletter from managers so all staff could read the communications which demonstrated the concerns were heard and actions were being taken to address the issues. There was a policy for staff raising concerns which provided guidance for how to whistle-blow and how to manage these protected disclosures.

Staff told us they were treated fairly and felt happy to work at the organisation.

Protected characteristics were demonstrated with reasonable adjustments being put into effect to ensure inclusivity and fair culture was integrated within the organisation. People were not discriminated against and were included in the workforce. Managers would discuss the need for flexible work with staff if required, to ensure work fit with their personal circumstances.

Processes were in place to ensure workforce equality, diversity and inclusion needs were met. Online advertisements were dedicated to support communities at specific times of the year, such as Pride Month and Men’s Health Week. Annual appraisals were in place for all staff to continually review practice and roles, but also to engage with staff.

We were told management were involved in audits and any resulting action plans. We reviewed multiple clinical records onsite which identified issues with records not being appropriately managed. The emergency clinical service did not appear to be fully understood regarding who audited the service. A number of records showed some staff carried their own procured medications. The manager was unable to adequately explain the reasoning for these records at the time and had not investigated them further. The manager was also unable to explain how errors were escalated. Clinical oversight was lacking, with clinical audits not being suitably performed and a misunderstanding of the management of controlled drugs being carried/administered by some staff.

The provider had applied for a Home Office license which would allow the provider to procure controlled drugs for use within the service, which they were still awaiting when we inspected. The medical director was able to clarify that some staff do carry their own procured medications in accordance with their license. The clinical manager sent a notice to staff after our visit to remind staff of their procedures regarding controlled drugs.

The managers were starting leadership training to encourage the organisation to be one team. The senior leadership team discussed the vision to expand the frontline service going forward.

Senior managers had weekly meetings where each head would update the group, ensuring there was oversight throughout the service. The regular senior management meetings would discuss which audits were being performed and when others were due. There was a risk log which managers updated and discussed at these meetings. The governance structure also included quarterly meetings with set agendas to ensure relevant policies were in place.

From the staff feedback survey a majority did not feel valued by the management team. There were irregular clinical staff team meetings, we were informed this was as it was difficult to get all the staff together at once due to shifts.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.