Sheffield Children's Hospital

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 assessed 1 quality statement under the well-led key question. The service benefited from committed and visible leadership, a positive culture and strong partnership working. However, governance systems could be strengthened by improved oversight of staff training and the implementation of a comprehensive audit programme to provide greater assurance regarding the quality and safety of service delivery.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

There were clear lines of responsibility and accountability within the service. A dedicated SARC manager had overall responsibility for the day-to-day operation of the service and for ensuring compliance with operational policies and procedures. The manager was supported by the clinical team lead, operational manager and divisional management team, providing both clinical and managerial oversight.

The service was actively working towards United Kingdom Accreditation Service (UKAS) accreditation. Staff were in the process implementing the quality management systems and governance arrangements required to meet accreditation standards, and progress had already been made.

A comprehensive suite of policies and procedures was in place to support the delivery of safe and effective care. These had been adapted to reflect the specific requirements of the SARC. Staff could readily access organisational policies through the trust’s intranet system. In addition, staff reviewed relevant Faculty of Forensic and Legal Medicine (FFLM) guidance every 3 months to ensure local practice remained aligned with current national standards and best practice.

The service had a clear incident reporting process, which staff understood and used appropriately. Staff told us they felt confident raising concerns and reporting incidents, and records showed reporting rates were proportionate to the size and activity of the service. Learning from incidents was shared with staff through governance processes and team meetings.

Feedback was actively sought from children, young people and their carers, and the responses we reviewed demonstrated consistently high levels of satisfaction with the service. Staff were frequently described as caring, professional and reassuring. Parents often commented on staff’s skill in engaging with their child and helping them feel at ease throughout their visit. Feedback was used to drive service improvements, including the introduction of age-appropriate games and activities for teenagers.

External stakeholders spoke positively about the service. NHS commissioners told us the service consistently achieved its key performance indicators and submitted required performance information in a timely manner. Police representatives described strong working relationships with SARC staff and reported that effective communication between agencies helped ensure children and young people received timely and appropriate care.

Staff consistently described the service as well led. They spoke positively about strong teamwork, supportive leadership and a collaborative culture. Staff told us they had sufficient time to provide compassionate, patient-centred care and felt valued by their managers.

Communication within the service was effective. Daily safety huddles and regular team meetings enabled staff to share information, discuss operational issues and maintain oversight of patient care and service delivery.

However, governance arrangements were not fully effective in all areas. Training records were fragmented across several systems and there was no single, accurate training matrix providing oversight of staff compliance with mandatory and role-specific training requirements. The service also had limited clinical audit arrangements. Although audits for infection control and record keeping were undertaken, there was no comprehensive audit programme or rolling schedule to ensure all aspects of service delivery were reviewed systematically. As a result, the provider could not fully demonstrate how quality and compliance were being monitored across all areas of the service.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.