255 Lichfield Road

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 changed to Requires Improvement.

Requires improvement: This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Leaders had the skills, knowledge and experience to perform their roles and staff knew and understood the provider’s vision and values and how they applied to the work of their team. Performance and risk were managed well. Staff collected and analysed data about outcomes and performance. They used this to identify improvements.

However,

The service was in breach of regulation for good governance. Staff were not always clear about their roles and responsibilities, and governance processes did not always operate effectively. Leaders had not notified CQC of a change in manager. They did not ensure appropriate levels of regular supervision of staff. They did not have effective communication systems and processes, that staff understood, to enable escalation of requests for additional staff.

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.

We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

Leaders told us that the hospitals visions and values were focused on delivering person centred care to ensure that people have a life that is meaningful, lived in safety and equality, and as part of the community.

All staff we spoke to understood the vision and values of the organisation and believed the hospital was delivering care in line with these values.

Most staff we spoke to told us there was a positive culture within the hospital. Staff told us that despite going through a process of change the team worked well, staff supported each other and were proud that their involvement had led to successful outcomes and achievements for patients.

We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. Managers understood the needs of the patient group and followed a recognised strength-based model of treatment and care that focussed on the patient’s skills and abilities.

Both patients and staff told us that managers were visible and approachable, and that management had an open-door policy.

Managers made themselves available for patients if they wanted to speak to them. We observed how managers knew the patients and offered support to patients when needed.

The service welcomed preceptorship nurses and offered supported nursing placements.

We create a positive culture where people feel that they can speak up and that their voice will be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. We saw that community meetings took place on a regular basis and that changes had been implemented as the result of feedback

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

The hospital had a Freedom to Speak Up Guardian. Contact details were displayed throughout the hospital.

Staff said they felt confident in raising concerns about poor professional practice or inappropriate conduct towards patients.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

Staff had access to equality, diversity and inclusion networks, including REACH (Race, Equality and Cultural Heritage), LGBTQ+, Disability and Difference, Armed Forces, Men That Talk, Menopause, Neurodiversity, Parents’ and women’s network. These allowed staff to connect with other colleagues from similar backgrounds in a safe and supportive environment.

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group.

We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate however we do not always have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support.

The provider did not always have clear responsibilities in relation to roles and systems of accountability.

Our findings from the other key questions demonstrated that governance processes did not always operate effectively at team level and that staff were not always clear about their roles and responsibilities.

The hospital had undergone a period of transition where the established manager had left and was currently under the charge of an interim hospital director. The Care Quality Commission had not been notified of these changes by the leadership team at the time they occurred.

Some staff told us this transition had been difficult due to the changes in management style and that communication of changes had not always been clear.

Some senior staff told us they were unclear of their roles and accountabilities since this transition but the hospital leadership were starting to make positive changes to ensure their roles were well defined and communicated to the rest of the team. Staff told us they had already seen encouraging changes with the recent appointment of a Director of Clinical Services.

The service did not have effective communication systems and processes, that staff understood, to enable escalation of requests for additional staff. Most staff told us the wards felt short staffed, and they struggled with managing workload to ensure that patients were not impacted. Although managers told us additional staff could be requested, when necessary, it was not clear that nursing staff and healthcare assistants felt able to or understood the process to do this. Staff told us they had shared their concerns around staffing levels with managers. The service shared with us the steps they had taken to discuss staffing models and the process to request additional staff within team meetings and emails.

Levels of clinical and managerial supervision had been low in the 6 months prior to our inspection. Leaders were aware of this and discussed during clinical governance meeting however no significant improvement was evidenced. The recent recruitment of a Director of Clinical Services was taking the lead on this work.

Leaders had governance arrangements in place and had relevant information at hand to review service performance.

Managers attended regular clinical governance meetings and had sufficient oversight from leaders within the organisation.

We reviewed monthly governance meeting minutes. These were attended by a range of staff. Key performance indicators and monthly audit processes were in place to help give oversight of the service. Managers had clear expectations of what care and support the service aimed to provide.

Robust processes were in place to safely manage sensitive data which allowed them to maintain people’s privacy, dignity and confidentiality.

The service had a risk register in place which clearly stated what the risk was, when and how it was raised and what mitigation had been put in place to help reduce the risk.

The service had plans for emergencies, for example, adverse weather or a infectious illness outbreak. The manager had implemented a series of in house training scenarios to ensure staff understood how to respond in the event of an emergency.

Staff had access to the equipment and information technology needed to do their work. Staff were waiting for radio equipment to access prompt support in the event of an incident.

We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies. Leaders told us that they worked positively with external agencies including various local authorities, other mental health providers, housing, and police.

External stakeholders were positive and complimentary about the leadership within the hospital, particularly the Responsible Clinician and Interim Hospital Director. We were told that the hospital worked collaboratively to ensure safe transitions and positive outcomes for patients.

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

The hospital focused on continuous learning and improvement across the organisation. The service had a positive and robust approach to improvement and learning from incidents and all staff we spoke to were able to give us good examples of where lessons had been learnt and changes made after incidents.

The hospital was proactive and responsive to feedback shared from external stakeholders. For example, we saw action plans and training had taken place for care plan development and improvement.