Transcare Secure Services - Birmingham

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 there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At the last assessment this was rated as requires improvement at this assessment we have rated this as good. This meant there was good leadership and a culture that created high-quality care.

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.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement.

The service had a vision and strategy in place which was based on providing a high standard of safe and secure transportation for patients within the mental health sector. There were 4 core values which underpinned the vision of the service. These were Safety, Teamwork, Authentic and Respect.

The culture of the team focused on patient safety and care. Staff told us the culture was friendly and supportive.

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.

Staff felt supported by their managers who were accessible and available and often involved in the actual transfer of a patients.

There was support available for staff who had been involved in an emotional or difficult situation and a de brief was carried out after every journey to allow staff to share feedback and their experiences.

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

Managers supported an open and honest culture. All staff we spoke with felt supported, respected, and valued. The culture encouraged openness and honesty. There was a freedom to speak up policy. Staff told us they felt able to raise concerns and they were listened to by the leaders of the service.

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

There was an up to date Equality and Diversity policy. Equality and diversity and human rights training was part of staff’s mandatory training programme; 100% of staff had completed this. All staff completed an annual employee survey.

The transfer request form identified if male or female staff were required to support the transfer, they ensured one member of staff was the same sex as the patient being transferred.

The service had responsibilities, roles, systems of accountability and governance. However, they did not always act on the best information about risk, performance and outcomes or share this with others when appropriate.

There was a governance process in place with management and accountability arrangements. Staff mainly understood their role and responsibilities. Information was discussed at staff meetings on audits and performance.

The clinical governance meetings were held monthly and discussed activity, staffing, policies, audits, complaints, incidents and safeguarding. However, this information was not always shared with all staff. Following our assessment the registered manager told us a dedicated messaging group has been created to dissemination information such as policies, audits, lessons learned from incidents and minutes of meetings to all staff.

There was evidence of regular audits being completed monthly, bimonthly and quarterly, this was an improvement since our last assessment. This included patient reported outcomes, care records, staff files, cleaning records and fire maintenance records. We reviewed examples of audits which had been completed. However, we did not identify that the actual audit results were always captured, discussed or actioned when they did not meet 100% compliance. Minutes of meetings identified they had been completed but did not always share the outcomes or results. Therefore, we were not assured that staff always acted on the results when needed.

The service had a risk register with 1 risk recorded, relating to the latest CQC report impacting on activity within the organisation. Other risks that would affect the service such as weather, staffing and vehicle failure were on the Business Continuity plan. Following our assessment the registered manager provided an up to date risk register with 12 risks that included risks, mitigations and review dates.

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

Leaders told us they had formed positive relationships with the stakeholders they were engaged with. The service worked with a limited number of stakeholders. Staff told us they intended to try and improve this and work with more stakeholders in the future. Leaders told us they believed their current CQC ratings had impacted on their work and as a result of this, only worked with a limited number of external stakeholders.

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

Staff told us they were committed to learning and improving.

The service provided evidence of actions taken following our assessment to provide assurance.

Since our last assessment the provider had implemented the following improvements

Ensured all staff had an up to date DBS. There was a process in place to review when they were required to be updated and discussed at each governance meeting. There service implemented a human resource monitoring tool which included reviewing DBS, rights to work, professional registration details and training requirements.

An up to date and relevant policy and processes were in place for managing medicines and safe storage. Medication travelling with patients would be stored in a sealed bag under the front seat. Staff no longer administered medication to patients during journeys.

Policies we reviewed were up to date, relevant to the service and had been approved by the governance processes.

On this assessment, there was evidence of regular audits being completed monthly, bimonthly and quarterly. However, we did not identify that audit results were always captured, discussed or actioned. Following our assessment the registered manager told us that they would include results from audits in meetings and share with staff.