Providence House and Moira House

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• 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

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 remained Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred 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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 through community meetings, surveys, complaints and by raising concerns directly to staff. There was also a service user improvement group which patients used to feedback concerns or suggest improvement to the service.

Patients and carers were involved in decision-making about changes to the service. For example, managers had purchased bean bags, arrange for games consoles in the activities room and arrange for a beautician to visit the unit following patient feedback.

Patients could meet with members of the provider’s senior leadership team to give feedback. Senior managers completed regular walk arounds where they engaged with patients. The safeguarding lead also completed drop ins for patients to have an informal chat with them and kept a log of feedback with actions identified.

Staff could also meet with senior leaders via fortnightly ‘drop in’s’ which included an allocated slot for staff to speak to them directly.

There was a nominated freedom to speak up officer within the service who staff could approach to support them in raising concerns. The freedom to speak up officer kept a log of all feedback and concerns and fed back themes and trends to managers during governance and assurance committees.

Staff and managers told us they felt able to raise concerns without fear of reprisals. Managers promoted the freedom to speak up process within the service and reminded staff that they could contact the freedom to speak up officer at any time.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Team meetings took place at both Providence and Moira House and were chaired by ward managers or a senior nurse. Meetings incorporated the sharing of information from governance and assurance committees, including learning from incidents, and any other relevant safety issues or alerts. They also provided a forum for staff to share any concerns, improvements and good practice. Other meetings included morning huddles, multidisciplinary team meetings, progress reviews, strategy meetings, safeguarding meetings and care planning meetings which were all well embedded.

The monthly governance and assurance committee meeting covered all relevant areas of clinical governance. Managers escalated and actioned any areas of concern arising from these meetings.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. Managers recorded all audit actions and arranged for follow-up audits where appropriate.

Managers used action logs, audit trails and compliance reviews to help embed a learning culture and ensure continuous improvement. Managers had oversight of safeguarding concerns, incidents and risk management and had access to the appropriate data to enable them to do so.

Staff and managers understood the arrangements for working with external teams, to meet the needs of the patients. There was evidence of effective joint working with the integrated care board, commissioners, and the local authority who had all completed recent quality visits to the service.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. The risk register contained 15 current risk which were graded in terms of severity, with controls and mitigating actions in place. The risk register showed that managers reviewed each risk regularly and removed risks where these were no longer present.

The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff. Staff spoke positively about the electronic care records system and described how it could be adapted to collect data, or to prompt staff to complete tasks. Information governance systems included confidentiality of patient records. Documents were password protected a staff used encrypted files

Managers told us they had access to information to support them with their management role including information on the performance of the service, staffing and patient care.

The service had plans for emergencies including adverse weather or a flu outbreak. There was a business continuity plan in place for the service which was reviewed regularly by the policy review group.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.