Archived: Dr J & Colleagues

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: 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.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a clear vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Staff and leaders demonstrated a positive, compassionate, listening culture. Staff we spoke to felt valued and supported by the organisation, however, reported lacking a clear understanding of its vision and strategy. The oversight systems to monitor the safety and quality of care for people were not used effectively. Management acknowledged the need for improvement and said there would be a renewed focus on governance and communicating a clear vision and strategy with frontline staff. We will continue to monitor this.

The provider had inclusive leaders who understand the context in which they deliver care, treatment and support and embody 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 told us that the registered manager had an open-door policy and could be contacted if support was needed.

We did not look at Freedom to speak up during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Workforce equality, diversity and inclusion during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

The provider did not have clear responsibilities, roles, and effective systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Systems were in place for oversight and governance but were not always completed effectively to ensure safe practice. For example, we were not assured that leaders can account for the actions, behaviours and performance of all staff. People raised concerns with us about the quality and timeliness of assessments. There was evidence that a backlog of assessments had sat unprocessed by one clinician, meaning people were left without treatment. Our review of incidents showed repeated confidentiality breaches where people were sent the wrong assessment reports and prescription containing sensitive information. Furthermore, the provider had not ensured sufficient oversight of clinical supervision for contracted staff. Staff told us that they were only required to inform the provider that supervision and appraisal had been completed and that there was no system in place to monitor the quality or content of the supervision or appraisal. The supervision compliance rate at the service for contractors was 86% and the appraisal compliance rate was 65%. There was limited evidence that staff undertook or participated in local clinical audits. Staff told us that formal auditing of prescribing practices among non-medical prescribers has not yet been established, and it was unclear who is responsible for managing drug safety alerts. However, the registered manager was passionate about the service and told us that they would improve their governance systems. We will continue to monitor this.

The provider understand their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement.

Leaders told us that they worked with marginalised groups locally to offer access to their services in collaboration with local medical charities and the local integrated care board. We reviewed minutes from a quarterly engagement meeting which showed that the provider had good links with local commissioners. The registered manager told us that the service also had access to support from a level 4 trained safeguarding lead for complex cases.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and the 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 contribute to safe, effective practice and research.

The provider had various systems for learning and improvement but did not always share learning with staff effectively. This meant opportunities to learn lessons and embed good practice were missed. There was limited evidence that appropriate checks on staff practices and processes were in place to ensure that staff worked in line with policy and national guidance. For example, our review of care records showed that staff used agreed assessment templates, but there we inconsistencies between clinicians in the level of detail provided during assessment and the inclusion of diagnostic tools. Staff told us that this had been raised with leaders, who were reluctant to use a more standardised approach with agreed minimum standards to improve consistency.

However, the service ensured that feedback was routinely gathered from people using the service and we saw evidence of improvements as a result.