Atrium Health Centre

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

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 as good. At this assessment, the rating has changed to requires improvement.

This service scored 54 (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.

Whilst staff told us they had contributed to the development of the service's vision and strategy, which was reviewed regularly, staff survey results completed by the service identified opportunities to further strengthen staff engagement, with approximately only 63% of staff reporting that they were able to share ideas at work. In response to this feedback, the service provided information on how it was committed to discussing internal policies at team meetings and had introduced a standing agenda item to encourage staff to share ideas and suggestions for improvement. Whilst the meeting minutes we reviewed only demonstrated significant events and learning as a standing agenda item, staff told us that proposed changes were discussed as a team, and they felt involved in shaping how the service developed.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Whilst some staff spoke positively about the leadership team based within the service on a day-to-day basis, and described them as supportive and approachable, others told us the leaders from the "central team" were not always visible within the service. Staff we spoke with said current senior leaders rarely visited the site or engaged directly with the team, which reduced opportunities to discuss concerns, seek support and share learning. Some staff felt this limited the leaders' understanding of the day-to-day operation of the service, local challenges, workforce pressures and the practical impact of organisational decisions on staff and people who use the service.

People did not always feel they could speak up and that their voice would be heard.

Whilst the service had a Freedom to Speak Up (FTSU) policy in place, 2 staff members we spoke with during our onsite visit were not able to identify who the service’s FTSU Guardian was. We noted information relating to the service’s FTSU Guardian was included within the service’s policy but observed no other information was available within the service to promote this to staff, such as who was undertaking it and how to raise concerns. This meant staff may not have had consistent access to clear, visible routes for raising concerns outside their immediate management structure, which could limit confidence that concerns would be heard and acted on appropriately.

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.

The service provided mandatory equality, diversity and inclusion training to all staff to support respectful and inclusive care for people from a wide range of backgrounds. Leaders promoted a zero-tolerance approach to discrimination and had arrangements in place to support staff wellbeing and inclusion.

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, or share this securely with others when appropriate.

Theservice did not have effective systems and processes to maintain oversight of key areas of service delivery, such as recruitment records, staff immunisation records, clinical supervision, clinical audit activity, and the management of DNACPR decisions. Policies did not always reflect current practice or guidance, required records were not consistently maintained or accessible, and in some cases the service was not following its own policy, for example, in relation to clinical supervision.

The service's systems for identifying, monitoring and mitigating risks were also not effective. Actions identified through historic fire risk assessments had not been completed in a timely manner, cleaning arrangements were not sufficiently monitored to ensure expected standards were maintained, and risks associated with furnishings and the environment had not been fully assessed or managed. In addition, arrangements for emergency medicines and equipment lacked effective oversight, with risk assessments, monitoring processes and routine checks not providing assurance that emergency equipment was complete, available and ready for use when required. Where decisions had been made to not stock nationally recommended medicines or equipment, these had not been supported by relevant risk assessments that fully mitigated the clinical risks associated with such decisions.

The service also did not always effectively monitor performance or use information to drive improvement. Systems used by the provider had not ensured that people received recommended reviews and monitoring for some long-term conditions, targeted action had not been clearly implemented or reviewed where cervical screening and childhood immunisation uptake remained below national targets, and information relating to some care and treatment decisions, including DNACPR decisions, was not always accurately recorded. Concerns raised by staff relating to the governance arrangements with the "central team" had also not yet been fully addressed.

The service also maintained a risk register; however, a number of actions remained incomplete, progress was not consistently tracked, and outcomes were not always measurable.

These concerns indicate a lack of effective governance arrangements to monitor performance, maintain accurate records, assess and mitigate risks, and ensure policies and procedures were implemented consistently across the service.

Ongoing concerns with cleaning standards, hand hygiene materials, clinical waste storage and soft furnishings meant leaders could not be assured that risks of infection transmission were consistently identified and mitigated. This also did not provide assurance that the IPC lead had the knowledge, support and oversight required to effectively carry out their responsibilities.

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

The service worked collaboratively with other organisations involved in people's care. Partner organisations and external professionals had access to a bypass telephone number, which connected directly to a designated phone-line for urgent enquiries and escalation where required.

To support effective partnership working, safeguarding and multidisciplinary team (MDT) meetings were held remotely, enabling professionals from different organisations to attend and contribute to discussions more easily.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Whilst the service had action lists, action plans and risk assessments in place; these were not always used as intended. Progress was not consistently tracked or monitored, and some actions remained incomplete once identified for long periods of time. An improvement plan reviewed during the assessment detailed planned actions and objectives, but did not include target dates, evidence of progress, or records demonstrating completion.

During the assessment, the service was unable to demonstrate that clinical audits, other than an anaphylaxis audit, had been completed to promote a culture of learning, improvement and innovation. The service was also unable to provide evidence of completed 2-cycle audits to demonstrate that improvements had been implemented, evaluated and sustained over time.