Archived: The Chimneys Clinic

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

Staff knew who the senior leaders were and told us they were visible. Staff demonstrated the vision and values for the service. There were robust systems policies, procedures and processes in place to oversee good governance and the management of the service, including mechanisms for learning lessons from safety incidents and complaints, processes for ensuring staff received mandatory training, appraisals and supervision and oversight of risks and challenges.

This service scored 82 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture.

The service set out 4 clear values, kindness, integrity, teamwork and excellence. Senior leaders had communicated the provider’s vision and values to the frontline staff in this service. Staff we spoke with demonstrated the provider’s vision and values and they were all clear about the aims of their service.

Staff described a positive culture within their own wards and across the wider service. They were proud of their work.

The service set out a clear patient pathway and philosophy for their care and treatment which staff applied in their day-to-day work.

The service had inclusive leaders who understood the context in which they delivered care, treatment and supported and embodied the culture and values of their workforce and organisation. They had the skills, knowledge and experience to lead effectively.

Staff and leaders were clear, and they understood their roles, responsibilities and accountabilities. They spoke with compassion about patients.

Staff spoke positively about local and senior leadership. Staff felt they were approachable, accessible and supportive. Staff said that senior leaders were visible on the wards.

The service aimed to create a positive culture where people felt they could speak up and their voice would be heard.

Staff said they knew how to raise a concern and would feel comfortable to do so. They were aware of the service’s whistleblowing policy and the freedom to speak up guardian. We heard an example where a member of staff had used the freedom to speak up process and they had been satisfied with the outcome.

Managers had access to feedback from staff via surveys and they devised action plans to make improvements.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service had a Diversity, Equity and Inclusion policy in place. Staff had completed mandatory diversity and inclusion training. At the time of the inspection, 99% of staff had received this training.

There were mechanisms in place to protect staff from discrimination in the workplace, (for example, the diversity, equity and inclusion policy, zero tolerance policy and freedom to speak up guardians),

Managers told us they were proactively working towards eliminating staff experiences of racism on the wards. We saw in the service risk register that the provider had a zero-tolerance policy in place and patients were issued with a zero tolerances letter that included racism, verbal abuse and physical abuse. A coproduction group was being developed to stop racism, this was a collaborative project with patients. The service worked in liaison with the police and the police were invited in to speak to patients and staff at community meetings. Staff were actively encouraged to complete incident reports for all racism at work or on the ward and to report racist acts to the police, we saw evidence of this recorded in governance meeting minutes. In July 2025 staff had reported an improvement in these incidents, there had been fewer incident reports made. The service continued to work towards making further improvement.

In the last staff survey of 2024/2025 82% of staff reported that they can manage their job responsibilities in a way that enables healthy work-life balance and staff we spoke with told us they had been supported to work flexibly due to their personal circumstances. One staff member also told us they had been well supported to return to work following a period of sickness.

The service had clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There was a clear clinical governance structure in place. Managers had oversight of risk in their service and knew what the challenges were. They used tools such as a risk register, incident log and PSIRF, complaints and concerns log, local and provider level audit and monthly quality management information to identify, record, monitor and take action on risks, concerns and issues. Managers had access to information to support them with their role. They reviewed monthly data that provided essential information on the performance of the service under the following 5 headings; patient experience, the care pathway, physical healthcare, staff support and wellbeing and governance.

We reviewed examples of governance and staff meeting minutes. There was a clear framework and agenda to ensure that essential information, such as learning from incidents, complaints, and safeguarding referrals were discussed and shared with staff. A patient representative also attended governance meetings.

Managers ensured staff routinely collected information and participated in clinical audits. There was a robust audit programme in place at both local and provider level including essential topics such as, care plans; enhanced observations; food and fluid intake; reducing restrictive practice and infection control the results of which were shared with teams.

Managers maintained and had access to the risk register. Staff at ward level could access this and add new items when identified. The risk register recorded the likelihood and impact of the issue. There were clear mitigations in place and the hospital director and/or medical team took ownership of the issues.

We saw that managers and staff had implemented actions from reviews of incidents, complaints and safeguarding alerts at the service level. We could see actions and lessons learnt from the incidents, complaints and safeguarding logs we reviewed as part of the inspection.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, generally worked well and helped to improve the quality of care. Information governance systems included confidentiality of patient records. Patient records were stored securely.

The service had plans in place for emergencies including business and major incident contingency plans.

The service understood their duty to work in partnership, so services worked seamlessly for people.

Leaders engaged with external partners such as commissioners to keep them regularly updated and maintained relationships with the local authority. Managers said they had good working relationships with these services.

Managers and staff understood the arrangements for working with others, both internally and externally, to meet the needs of the patients. They encouraged patients to access local organisations for social engagement for example, the library, sporting activities, theatre and the cinema. Patients participated in educational activities through external opportunities. We saw 1 patient had undertaken a work opportunity at a local charity shop. Facilitated by the occupational therapy team, patients had used their creative skills to make items for sale at a pop-up shop in the local library and local craft events. The money raised was put towards charitable funds including men’s mental health and hearing dogs for the deaf. The service had worked with patients to understand earnings, benefits and taxes to help prepare patients for careers in the community.

The service encouraged continuous learning, innovation and improvement.

The service had a monthly Quality Improvement newsletter. We saw examples of a range of quality improvement initiatives and co-production projects, which were patient lead. There had been a patient focus group to look at how the ward structure and daily timetable could be improved.

The service held a parents’ forum as a means of co-production. The service recognised the importance of hearing what family and carers had to say and to have a space to talk to build and develop the service together.

We saw a co-production project plan was in place for tackling racism, to bring together staff and patient collaborators to explore and address experiences and perceptions of racism directed toward staff.

Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. They had opportunities to feedback in meetings, supervision, and through a staff survey.