Church View - Princess of Wales Community Hospital Also known as Church View

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 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 that the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to the governance of the service.

This service scored 57 (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 did not always have a shared vision, strategy and culture. This was not always based on transparency, equity, equality and human rights, diversity and inclusion, engagement and understanding challenges and the needs of people and their communities.

There were 5 core values across the workforce: Courageous, Ambitious, Responsive, Empowering and Supportive. The trust’s vision was “Working Together for Outstanding Care.” Most staff we spoke to could name the 5 core values or told us they knew where to find further information. Whilst the provider had this in place at the service, the values were not always effectively implemented.

Leaders did not always ensure that autistic people and people with learning disabilities lived ordinary lives like any other person. There was a lack of provider oversight to ensure that the “Right support, right care, right culture” was being considered in accordance with guidance.

Leaders did not always have the skills, knowledge, and experience to lead effectively. We identified breaches of legal regulations and concerns in areas such as safe care, safeguarding, Mental Capacity Assessments and consent and governance. Leaders had not independently identified some of our concerns as they were not acted on prior to our assessment, for example, there was a lack of escalation from identified safeguarding concerns.

Staff were positive about management at the service. A member of staff told us “I know who all the senior leaders are, I have even worked a shift with [name of leader.] Another member of staff told us “I am supported by management in my line of work, even anyone above my direct management would be approachable.”

Staff felt they could speak up and their voice would be heard. Staff felt able to raise concerns with management and felt they would be listened to. A staff members told us, “I would definitely feel happy to raise this.”

The trust had a Freedom to Speak Up guardian and an established process for staff to confidentially raise concerns. All staff we spoke with about this topic told us that they were aware of how to use the Freedom to Speak Up process or knew where to find further information on this process.There was a whistleblowing policy in place to support speaking up.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The trust had a range of staff networks, including ENRICH (Equality Network for Race Inclusion and Cultural Heritage,) Staff Disability Network and the Carers Staff network.

Staff could apply to work flexibly and flexible working arrangements were in place to account for personal circumstances such as health issues.

The trust has an Equality, Diversity, Inclusion and Equity Strategy (EDIE,) called “Harmony in Diversity: Creating a Community for All.” The strategy sets out 6 objectives with measures of success and timeframes for completion, including increasing the diversity of their workforce.

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

The provider produced a monthly integrated governance report that measured progress against the Care Quality Commission’s key questions and fundamental standards of care. The monthly reported had metrics to measure progress against these standards and any measures of mitigation in place. For example, the report looked at staffing levels at the service and documented the impact on people’s care and support.

However, systems did not effectively assess, monitor or improve the quality and safety of the service or mitigate risk. Provider audits had not identified the concerns we found during our assessment, such as safeguarding, mental capacity assessments, risk management, and poor record keeping. This raised concerns about the effectiveness of governance and oversight processes. For example, systems and processes in place were ineffective in identifying shortfalls in the investigating and reporting of unexplained injuries, this meant that may have been missed opportunities for learning and improvement. Care records were not always accurate. Prior to our assessment, there was no schedule for auditing care plans and risk assessments. Although care plans were annually reviewed with people and relatives, systems and processes were not robust in identifying gaps and inconsistencies within care records. Furthermore, the provider was in the process of changing their electronic record system and storage of records was inconsistent, this could make it difficult for staff to find the correct information at the right time. The provider told us that care plans and risk assessments would be audited monthly in response to our findings.

Although, the provider acted in response to the concerns we identified to reduce ongoing risks to people; however, improvements were required to ensure systems and polices were fully understood and embedded at the service.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Management told us they had good relationships with other professionals involved in people’s care, including the local authority. However, we found that there was a lack of oversight in sharing key information about individual people and reporting incidents to relevant partner agencies.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged ways of delivering equality in experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The trust had quality improvement training available for all staff (Quality, Service Improvement and Redesign (QSIR) programmes) to support quality improvements at all levels. Staff could apply for introductory, intermediate or advanced level training and could further information of quality improvement initiatives on the intranet. The leadership and management training also had a module on quality improvement.