Head Office

Leaders and staff knew the service’s local vision, aims and objectives and understood how their service aligned with this. There was a culture based on speaking up, listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Leaders had oversight of the quality of service through digital dashboards which provided real-time and visual monitoring of clinical and operational domains. There was an effective governance structure and risk management systems. There was a culture of continuous improvement with staff able to contribute ideas through a quality improvement programme. However, audits and record keeping for infection prevention control were not always completed to ensure infection control measures were consistently applied to maintain high safety standards. Leaders were not submitting statutory notifications following notifiable incidents in line with their conditions of registration. However, these were submitted retrospectively following the onsite assessment.

We found a breach in good governance.