We are With You Wigan and Leigh

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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the service did not always have effective oversight and governance processes that were fully embedded.

Although the service had governance processes and procedures in place, these did not always operate effectively, and it was not always clear that managers had appropriate oversight and monitoring of these processes. We identified gaps in various documentation that we reviewed, along with incomplete processes or pieces of work.

However, managers were reviewing the service and making improvements to areas of work.

Staff generally gave positive feedback about working for the service and in particular about the management and leadership.

The service was in breach of regulation for governance at the service.

This service scored 62 (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. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and how this was applied in the work of their team. Staff understood the importance of the service that they were delivering to clients and reflected on some of the positive impacts and changes they had been able to make.

Managers felt that staff were mostly passionate about their work and in wanting to help people in a compassionate way.

Managers were in the process of implementing some changes in the service and identified that it was important that staff were kept informed and involved in the decisions that were being made.

Staff could explain how they were working to deliver high quality care within the budgets available.

Managers explained the differences between the two locations both in terms of the actual area but also in respect of the demands and pressures on staff. Managers were keen to ensure they had effective oversight of both locations and any specific challenges each site might be facing.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The service had two registered managers at the time of the assessment, who were the Head of Service Delivery and one of the Clinical Leads. Both had been in post as registered managers since 01 April 2025, although were experienced managers from another location within the organisation.

The service had made changes to how the management was structured, which included adding an additional Clinical Lead post so there was now two for the service; whilst the number of Operations Managers had also increased to four.

The Operations Managers each had specific teams and areas of work allocated to them. It was noted that the increase in number of Operations Managers had helped to reduce demand on capacity at that level and enable them to support their teams more effectively, along with having better oversight.

The Head of Service Delivery was considering how managers worked across the two sites and was looking at making some changes to see if this improved oversight and monitoring within the service.

Staff gave positive feedback about the Head of Service Delivery including that they were visible, supportive and dynamic in their role, which was assisting with the ongoing development of the service.

Managers were open and honest when discussing the service and were receptive to feedback given during the assessment. Managers recognised that work was still required to develop the service in line with their aspirations and were passionate about ensuring that this was achieved.

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

The service had policies and procedures to support whistleblowing and the freedom to speak up. Staff were aware of how to access support and generally felt confident that they would be able to do so if needed.

Managers promoted an open and honest culture. Managers described positive and open relationships with staff and gave examples of where staff had raised issues or concerns with managers as needed.

Staff understood these policies and felt comfortable using them without fear of reprisal

The service had utilised client surveys to gather feedback on the service and had considered changes that could be made based on this feedback.

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

Staff received mandatory training in equality, diversity and inclusion with compliance rates of 77.3% for existing staff and 82.9% for new starters. The remaining staff were either in their 3-month refresh window period for the training or were new starters who were in progress with the training, meaning they were not considered to be non-compliant.

Managers were reflective and considerate about different ways that they could support staff or best meet individual needs.

Staff gave positive feedback about how managers had supported them such as by making reasonable adjustments to help them carry out their roles.

The organisation had equality, diversity and inclusion commitments which they were embedding to reduce inequalities in the workplace and in the service being delivered.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

Although the service had governance processes and procedures in place, these did not always operate effectively, and it was not always clear that managers had appropriate oversight and monitoring of these processes. We identified gaps in various documentation that we reviewed, along with incomplete processes or pieces of work. This included a significant gap in the panic alarm testing at both sites, some missed months for the monthly environmental checks, an open complaint which had been open on the system since January 2025 without actions taken on it, and the service supervision tracker which was not being updated or used for oversight at the time of the assessment.

We reviewed monitoring paperwork for blank controlled drug stationary at both locations and identified, predominantly at Wigan, missing counter signatures and poor practice being used when recording. This was in relation to the handling of FP10 controlled drug stationary. At Wigan, multiple examples of missing counter signatures were identified whilst similar issues were identified at Leigh but on a much lower scale. The records also indicated poor practice being used by staff when recording and signing, such as using the “as above” symbol in place of using their full signatures along with examples of correction fluid being used instead of crossing over the mistake and countersigning. The use of correction fluid was on multiple records at Wigan and in one of the records at Leigh. These did not relate to completed prescription forms and were not a direct risk to client safety. The service’s audit processes or checks had identified that FP10 handling monitoring documents were not being completed correctly at the Leigh service, although it had not been identified in the audit for the Wigan service, meaning that these processes had not always been effectively used to have appropriate oversight and monitoring of these records.

Managers had recently streamlined and reduced the meetings that were being held in the service following feedback from staff and leaders, who felt that the previous structure did not assist them in managing and having oversight of the various tasks and actions. Managers described a positive impact of the change in meeting schedule.

Managers were also developing a new agenda for service meetings that all staff could attend and had decided that these would be held face-to-face on a quarterly basis. The first of these meetings was scheduled for the start of August 2025.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

External partners and stakeholders generally gave positive feedback about their working relationships with the service. This included regular, ongoing meetings along with open and effective communication between the service and the external partners.

Some of the external partners and stakeholders acknowledged that there were some improvements that could be made within the service, however, they were confident that progress was being made by the service in addressing these areas.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service had received an internal audit by their organisation earlier in 2025. The report for this was produced in April 2025. Managers had developed an action plan to address the areas for improvement that had been identified through this process. Managers were monitoring how the service was progressing against these actions within regular meetings.

The service was piloting the use of an artificial intelligence programme to support staff with their notes to reduce the burdens on staff on a day-to-day basis. The pilot was due to last for 6 months. Managers noted that staff had given some positive impact about this.