The Limes

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

Well-led – 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 remained Good. This meant the service was consistently managed and well-led. Leaders and the culture of the service promoted high-quality, person-centred care.

Staff understood and promoted the services vision and values and knew how they applied to their role within the service. Staff felt respected, supported and valued. Governance processes were effective. Performance and risks were well managed. Staff throughout the service had access to the information they needed to provide safe and effective care. Staff pro-actively collected and analysed data about outcomes and performance. They used this to continually drive improvement for the service, which enhanced the experience for staff working within the service, and the patients they supported.

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 co-designed the services strategy, and understood the vision and values of the organisation, and described how they applied them in their day-to-day work. The provider’s purpose, vision, and mission to deliver safe, compassionate care within a culture of openness, honesty, and inclusivity were clearly communicated and visible across the service. Managers explained that values, culture and practice had evolved and been shaped with input from patients, their families and staff, and were embedded into recruitment, training, supervision, and decision-making regarding disciplinary matters.

Senior leaders modelled behaviours, and enthusiasm which promoted an open culture with a clear emphasis on equality, diversity and inclusion. Leaders held regular engagement meetings with staff and completed drop-ins for staff working night shifts which fostered a culture of inclusivity. Managers encouraged responsibility throughout their teams, with staff having lead roles, such as a service co-production champion, freedom to speak up champion and safeguarding lead.

Staff, patients and their families had opportunities to contribute to discussions about the strategy for their service. Managers shared updates through regular meetings, and internal and external information sharing, ensuring all staff were kept informed. Both clinical and non-clinical staff benefited from tailored training packages to ensure they understood the environment and patient needs, such as additional diagnosis specific training and promotion of mental health rehabilitation.

Leaders ensured all staff received regular and clear communication promoting the shared goals and direction of the organisation. Staff felt included and valued, which fostered and promoted a positive culture within the service.

Leaders at all levels demonstrated the skills, knowledge, and experience needed to perform their roles effectively. They understood the services they managed and could clearly explain how their teams delivered safe and effective care. Leaders were visible, available and approachable to staff, patients and their families. Staff reported that leaders maintained an open and transparent culture, where any issues could be raised without concern. Leaders promoted an inclusive culture underpinned by openness, equity, diversity, and respect.

Leaders fostered a culture of development, and progression within their teams, with all staff having a progression and development opportunities which were visited regularly through supervision, and appraisals. Staff received support to develop their skills, and non-clinical staff were offered additional training to build understanding of the environment and service. Leaders valued their staff teams and proactively challenged and addressed any cultural issues that could impact care or have a negative impact on the wellbeing of staff.

Managers provided a clear framework which supported staff to raise concerns. A whistleblowing policy was available, and posters displayed throughout the environment outlined how to access the service. A designated freedom to speak up champion was available on site to offer support to colleagues, and an organisational Guardian was available, and provided confidential advice and support, this ensured staff could raise concerns outside of their local service if they felt they needed to. There had been 2 freedom to speak up concerns raised in the 3 months prior to our visit, we found evidence that both concerns had been acknowledged, investigated thoroughly with positive outcomes achieved for all involved.

Managers also promoted a “Don’t ignore it, Report it” campaign. Staff felt confident raising issues without fear of reproach. Managers promoted openness and transparency and acted with integrity when concerns arose. Leaders investigated and shared learning to drive improvement.

Leaders ensured escalation routes were available beyond the local service. Staff, had opportunities to meet with senior leaders on a regular basis, further strengthening the culture of openness. When things went wrong, leaders demonstrated honesty and transparency. Staff reported that patients received timely explanations and apologies when needed, along with information about actions taken to prevent re-occurrence.

Managers supported flexible working arrangements for staff to accommodate caring responsibilities, health needs, cultural needs and other personal circumstances. They put reasonable adjustments in place to help staff carry out their roles effectively. The service monitored workforce equality through formal mechanisms, including the race and ethnicity employee resource group and the disability employee resource group.

The service participated in a successful sponsorship programme for overseas staff, and a dedicated organisational sponsorship team provided comprehensive support with all aspects of employment and relocation. The providers human resources, and wellbeing teams also provided overseas staff with ongoing support. Leaders ensured that all overseas staff completed role-relevant training and competencies prior to commencing work. They felt listened to, valued and were recognised by colleagues for their positive contributions and roles within the service. One staff member told us “I’ve been here for about 2 years now, and the support I got when I first came has just continued. It’s a great organisation to work for, and I feel so proud to be part of this team.”

Managers, and their staff celebrated the cultural diversity of their workforce with patients and held cultural awareness and themed days, such as, black history month, African heritage days and interfaith harmony events. Staff and patients also held international mother language days, where they celebrated different languages and communication, which promoted inclusion, education and gave an insight into diversity and culture.

Leaders fostered a culture of inclusion and promoted a zero-tolerance stance against bullying and harassment. They also endeavoured to ensure that all staff, including those who may be less heard, had input into shaping services. Equality, diversity and inclusion was clearly embedded in the organisation’s values, policies and strategic priorities.

Clear governance and management processes were in place, and worked well, which supported safe, high-quality and sustainable care. Leaders implemented a clear framework for ward and team meetings to ensure all information was effectively shared and discussed. Staff reviewed and analysed data, such as incidents, complaints, and safeguarding alerts, and implemented recommendations at service level. Staff participated in local clinical audits and acted on any findings.

Collaborative working within the services wider teams and externally was promoted to meet patient’s needs, for example the getting it right first time rehabilitation network. Leaders attended quarterly registered managers meetings, monthly regional clinical governance meetings, daily regional operations meetings, occupancy meetings and incident escalation meetings, with any external recommendations being discussed and implemented where appropriate.

Staff maintained emergency plans for adverse weather, flu outbreaks, and other contingencies. Senior leaders and managers accessed timely, and accurate information on service performance, staffing, and patient care, enabling them to identify areas for improvement. Leaders implemented recognised quality frameworks and supported innovation through effective and proportionate risk management practices. This ensured that governance structures remained resilient, flexible and sustainable.

Leaders, and their staff were open, transparent and effectively engaged with external stakeholders and partners in care. They collaborated with commissioners, care managers and other relevant organisations to support and maintain service delivery and integrated care.

Leaders shared learning across local and national networks and used partnerships to support and drive improvement within the service. For example, collaborative working and information sharing with the NHS national rehabilitation network, and NHS mental health services data set. Mental health services data set was a patient level data set which aimed to deliver robust, comprehensive, nationally consistent and comparable person-based information for patients who were in contact with mental health services. Information submitted was used by commissioning services, fed into clinical audits and research, assisted and informed service planning, inspection and regulation, local and national performance management and benchmarking and was collated for national reporting and analysis.

Integrated care pathways enabled effective information sharing with the services GP provider, for example, diabetes management and care. This ensured a shared care approach was maintained and supported the patient’s physical health needs which enabled them to improve their rehabilitation and recovery outcomes.

The service took part in local projects, and community activities. For example, patients visited a local farm recovery project which specialised in therapeutic horticulture and provided experience of the workplace environment. The project facilitated numerous activities to enhance the patient’s rehabilitation and recovery outcomes, such as, animal Care activities, unique and Bespoke workshops, training opportunities and help to find work and other opportunities with a dedicated progression Worker. It also provided a sense of belonging and a safe place to connect with likeminded people and an opportunity to work with people from different backgrounds. The project ran for 12 weeks, but patients had the option to stay on at the farm once the 12 weeks had ended.

Staff and leaders promoted networking, and engaged with patients, communities, and partners to share learning that resulted in continuous improvements to the service. Networks were used to identify new or innovative ideas, and practice that could lead to better outcomes for patients.

Leaders had a strong focus on continuous learning, improvement, and innovation across the service. Staff developed and implemented innovative projects, which led to improvements in patient care and outcomes. For example, a quality improvement project to streamline generic organisational clinical audit tools to make them more relevant and personalised to their service. Staff personalised audit tools to the service and the needs of the patient’s, all actions were named which ensured completion and accountability, staff implemented a 12-month audit schedule and staff at all grades were involved which gave them a better understanding of what was required to ensure compliance and quality across the service. The project effectively improved patient’s outcomes and improved their safety by ensuring evidence-based practice was meeting both standards, expectations and promoted a culture of continuous learning, improvement and quality assurance.

Staff completed a quality improvement project and supported patients to design and deliver in house training to staff to improve quality, safety and humanity of care. Leaders completed a training analysis of their service and looked at potential areas of need and what staff and patients would benefit from. Questionnaires were completed by both staff and patients regarding what training they thought would benefit them and enhance their practice, and what patients thought would help them if staff’s knowledge was improved. Training packages were co-produced with the psychology team and patient’s, training days were arranged for all staff and training was co delivered by Psychology staff and patients. The project resulted in, better understanding of diagnosis and effects, understanding the effects first hand rather than from a textbook, shifted perspectives, reduced stigma, enhanced person-centred care and fostered a culture of empowerment & purpose.

Innovations extended to risk reduction, restrictive practice management, safe wards and trauma-informed strategies were integrated which further enhanced safety and patient care. Staff engaged in research and embedded evidence-based practice into care delivery. Strong external links supported innovation. Leaders maintained open and clear communication with staff and promoted a culture of trust and involvement where ideas for change were encouraged, welcomed and acted upon.