Outpatient Services

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 they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. 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 values and how they were applied in the work of their team. Staff at all levels spoke consistently about the organisation’s therapeutic and trauma-informed values.

There was a shared vision around delivering safe, inclusive and recovery-focused care.

We reviewed meeting minutes, supervision records and appraisals that demonstrated that leaders had communicated the provider’s vision and values to the frontline staff in this service. Values were embedded in recruitment, induction, and ongoing staff development.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially during times the service was changing in structure or focus.

Staff could explain how they were working to deliver high quality care and felt involved in shaping service improvements and took pride in their work.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. 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.

Leaders had the skills, knowledge and experience to perform their roles.

Leaders were visible in the service and approachable for patients and staff.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

Leadership development opportunities were available, including opportunities for staff.

Senior staff demonstrated insight into the strengths and challenges of the service and took ownership for improvement.

There was a strong focus on values-led leadership, with clear communication and an emphasis on learning.

People using the service benefited from a culture shaped by calm, accountable leadership.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff reported feeling confident to speak up and raise issues without fear of reprisal.

There were clear pathways to escalate concerns, including access to external whistleblowing contacts. Freedom to Speak Up processes were in place across the wider organisation.

Concerns raised were documented and reviewed at governance meetings by service leaders, with actions followed up.

Leaders promoted psychological safety and maintained a ‘no-blame’ culture in reflective discussions.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. 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 told us they felt included, respected, and supported regardless of background or identity.

The provider promoted equality through training, reflective practice, and recruitment processes.

Leaders monitored diversity data and used it to identify areas for action.

Staff were encouraged to explore and challenge bias within the context of therapeutic work.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service had clear reporting structures and accountability across all levels.

Governance meetings were held regularly, with a set agenda and actions tracked and followed up at each meeting.

Quality assurance processes, such as audits and supervision, were embedded and informed improvement.

Leaders demonstrated good oversight of risk, training, and service performance and any identified risks were monitored via a risk register.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

The service had plans for emergencies – for example, adverse weather or a flu outbreak.

Staff had access to the equipment and information technology needed to do their work.

Information governance systems included confidentiality of patient records.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

Information was in an accessible format, and was timely, accurate and identified areas for improvement.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. 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.

Staff worked in partnership with NHS services, ICBs, probation teams, and veteran organisations.

The provider contributed to local and national networks to share learning and influence care pathways.

There were clear protocols for integrated working with other agencies, particularly in the autism and criminal justice pathways.

The service was proactive in supporting community re-engagement for people following treatment. We reviewed records relating to an incident where a service user had disengaged suddenly following diagnosis and then withdrew from treatment. The records demonstrated the service were proactive in liaising with the GP service, mental health community teams and with the commissioners to highlight that they were some concerns with the patient.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. 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.

Service users were given opportunities to feedback about the service including a QR code which provided a link to a survey based on the friends and family test. For example, a recent change of service name had been prompted by feedback from service users.

Staff were supported to develop opportunities for improvements and innovation and this led to changes in care delivery.

Staff used quality improvement methods and knew how to apply them.

Staff participated in national audits relevant to the service and learned from them.

Staff regularly reflected on practice and contributed to service improvement initiatives.

The provider evaluated outcomes to inform learning and shape service design.