My Recovery Tameside

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

At our last inspection we rated this key question good. At this inspection 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. Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance and used this to identify improvements.

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, 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. All the staff we spoke with were aware of the provider’s stated values of being “open”, “bold” and “compassionate” and the organisational mission to “transform people’s lives by providing community centred services based on evidence and compassion”.

Staff could explain how they were working to deliver high quality care within the budgets available. Managers and staff had an innovative and creative approach to delivering their service so as to maximise the benefits for clients within the service’s limited budget.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially when the service was changing. At the time we inspected the registered manager had introduced some drop-in surgeries for staff to provide them with extra support due to some uncertainty caused by recent management changes within the organisation. The service also arranged development days for specific staff groups, for example the nursing team, which included team building and wellbeing activities. Staff told us they felt well supported by immediate managers and by the registered manager.

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. All staff and external stakeholders who gave us feedback spoke highly of the registered manager and said they were knowledgeable and highly committed to delivering the best care possible for people using the service. Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

There were effective systems of quality monitoring and clinical governance in place and the registered manager was involved many aspects of these including monitoring incidents and complaints and reviewing audit findings and the service’s performance against key performance indicators.

The registered manager attended leadership meetings to meet with other service managers and more senior leaders within the wider organisation and shared information effectively both within these forums and in cascading messages down to the Tameside team. Staff told us that more senior leaders within CGL also regularly visited the service and we saw that staff had access to video conferencing sessions with the CGL senior leaders regularly.

Leadership development opportunities were available, including opportunities for staff. The registered manager had undertaken leadership training funded by the organisation and staff told us they felt well supported in relation to their career development. This included staff having access to funding for additional qualifications, for example nurse prescriber training.

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

People using the service had opportunities to give feedback on the service they received in a manner that reflected their individual needs. This included links to online surveys and suggestion boxes in both reception areas. Managers and staff had access to the feedback from clients, carers and staff and used this feedback to make improvements. Information on improvements made as a result of feedback from clients was displayed in the reception areas of both sites in a “you said, we did” format. Staff had access to a confidential ‘freedom to speak up’ process and the staff we spoke with felt they could raise concerns without fear of negative consequences or reprisals.

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.

All staff received equality, diversity and inclusion training as part of their mandatory training and 100% of staff were up to date with this at the time we inspected. None of the staff we spoke with raised any concerns about experiencing any discrimination or unfair treatment and the only formal grievance raised in the 12 months prior to our inspection did not include any concerns about discrimination due to any protected characteristics.

Staff were able to apply to work flexibly to account for personal circumstances such as caring responsibilities and health issues and managers put reasonable adjustments in place to support staff members to carry out their role where required.

The service monitored demographic data for staff and participated in a number of diversity events including Tameside LGBTQ+ Pride and an internal celebration event for Black History Month. Staff had the opportunity to join a number of diversity networks including the accessibility forum, race equality forum, LGBTQ+ forum and menopause group for connection and support.

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.

There was a clear framework of what must be discussed at team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Team meetings had standing agenda items and evidenced that learning from complaints, incidents and the deaths of people during an episode of treatment with the service was shared with staff regularly. Staff undertook or participated in local clinical audits, including medication audits, care records audits and environmental health and safety and infection prevention and control checks. The results of audits were shared with the local team and reported within the governance framework for CGL more widely. Learning was also shared from external and internal quality monitoring processes taking place within the wider organisation at team meetings and through regular staff bulletins.

The service had a risk register which was regularly reviewed and there was a system for staff to escalate concerns to this when needed. The service’s performance against a range of key performance indicators was monitored through a quarterly report, these included both internal benchmarks and targets and national indicators set by the Office for Heath Improvement and Disparities (OHID).

The service had a business continuity plan for emergencies, for example, adverse weather, IT failure or a severe flu outbreak.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care and ensured that people’s personal information was stored securely and confidentially.

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.

The service worked collaboratively with other services in the wider health and social care and criminal justice systems for the benefit of clients. We received very positive feedback from external stakeholders about how the service worked in partnership with them. Stakeholders told us that the registered manager was open and improvement focused and that information was shared appropriately. For example, stakeholders told us that “the service has consistently attended and contributed positively to statutory meetings, health collaboration meetings, and wider partnership forums, demonstrating a strong commitment to collaborative working across the system” and “the team are very proactive and are always looking for new and innovative ways to support service users in Tameside”.

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.

Staff were given the time and support to identify opportunities for improvements and innovation and this led to positive changes. The registered manager told us about ongoing work to improve and innovate within the service, for example the introduction of an ageing well clinic for clients aged over 50, which they had been asked to present to CGL’s national nurses’ meeting as an example of good practice.

The young people’s service in Tameside had also worked in partnership with local schools to develop a programme of education about drugs and alcohol, which was being rolled out to other CGL services nationally due to the positive impact this had. The service had also been involved in some successful pilots of changes to CGL systems and processes in the 12 months before our inspection, including improvements to the titration pathway for opiate substitution treatment and the roll out of the new criminal justice pages within the record keeping system.