23MD

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

This is the first inspection for this service since its registration with CQC under this provider. This key question has been rated as Good. This is because we found no issues with the governance and oversight of the service.

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.

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.

All staff had contributed to the development of the service vision and strategy, which was kept under review.

The service had inclusive leaders 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.

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

The service had established Freedom to Speak up arrangements. Patients we spoke with were aware of how to raise concerns if they were not satisfied with the service.

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.

Policies and procedures to promote diversity and equality were in place.

The service had clear responsibilities, roles, systems of accountability and good governance in most areas. However, we found some gaps in recruitment checks. The service delivered good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The doctors were involved in peer reviews regularly to ensure clinical governance. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Staff took patient confidentiality and information security seriously.

Feedback from people using the service was positive.

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

The service focused on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. For example, both doctors accessed external seminars and peer networks to stay updated on current practices, and learning from these sources was implemented.