Treat It 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

This key question has been rated as requires improvement. The service was in breach of legal regulation in relation to governance. Leaders and staff had a shared vision and culture. Leaders were accessible, knowledgeable and supportive, helping staff develop in their roles. However, these should have been identified through the provider’s own internal quality assurance systems. The provider had taken action following the assessment to review and improve systems, but it would take time to check and audit that these were effective.

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 and engagement.

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.

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

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

The service had governance systems in place. However, these were not operating effectively to provide sufficient assurance. For example, there were gaps in the checking and recording of patient identity, and outcomes from multidisciplinary meetings were not consistently documented. Patient record systems were fragmented, which made it difficult for staff to obtain a complete overview of a patient’s care and limited the service’s ability to carry out effective audit and quality improvement activity. There were also gaps in the policies and processes relating to transitioning patients onto shared care agreements.

These issues were identified during our assessment, but had not all been recognised through the provider’s own governance and oversight processes. Following the assessment, the provider took immediate action to mitigate risks and strengthen systems to protect patient safety. However, it was too early to determine whether these changes had been fully embedded or sustained.

The leaders worked well in the wider network of cannabis-based products for medicinal use (CBPM) services.

Leaders demonstrated a commitment to continuous learning, improvement and innovation. However, the service could not always use patient outcomes to inform learning or drive improvements. Audit activity was also limited due to the use of disjointed systems, which restricted the service’s ability to monitor performance or identify trends effectively.

Following the assessment, the provider took action to address the concerns raised and began strengthening systems to support learning and improvement. However, further time is needed to evaluate and evidence the positive impact of these changes.