Thomas Linacre Centre

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.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent in places. Leaders in the adult outpatients service and the culture they created did not always support the delivery of high-quality, person-centred care.

We found that the adult outpatients service lacked local or divisional strategic objectives, which meant that staff and teams did not have a unified understanding of the service’s intended direction. There were concerns amongst staff that leaders in this service were not always visible or supportive of concerns, and that they were not always engaged sufficiently with changes or developments. The adults outpatients service had not fully considered the sustainability of the business in the absence of its local leads.

However, leaders were competent and well qualified for their roles, and effective systems were in place to ensure inclusivity amongst teams. All outpatients services were well integrated into the community they served and gave staff opportunities to develop the services they offered.

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 scored the service as 1. The evidence showed significant shortfalls. The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The trust had a values and behaviours framework which had been produced in collaboration with staff. The framework consisted of ‘People at the Heart; Listen and Involve; Kind and Respectful; and One Team’, and guidance was available on how this should be embedded into services. The trust also had produced “Our Strategy 2030”, a strategic plan for the decade 2020-2030, which consisted of priorities and themes intended to guide how services should develop.

However, neither the outpatient service at the location, nor the division encompassing outpatient activity more broadly, could demonstrate a local strategy or any development objectives that were derived from the trust’s overarching frameworks. We noted that staff communications and trust documentation sometimes included visual reminders of the trust’s values, but these were not typically referenced in the text or clearly embedded into service delivery.

As such, staff could not tell us what the vision, values or objectives of the service were. Staff appraisal documentation further highlighted this, which included a section for the appraisee to document their division’s objectives; we saw 3 recent appraisals that each referenced a different set of objectives that weren’t clearly derived from trust frameworks.

When we spoke with staff, most felt that the culture and morale of the service had deteriorated in recent years, with leaders having a sole focus on operational efficiency. Some felt that the only way changes were made in the service would be when something jeopardised how many patients could be seen. However, all staff demonstrated an understanding that attributes such as mutual respect or focusing on patient-centred care were important, which was mostly aligned with the trust’s values.

We scored the service as 2. The evidence showed some shortfalls. Leaders did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

While staff in the adult outpatients service broadly felt that leaders were competent and effective in managing the daily operations of the service, many felt that more senior leaders were not visible or accessible to them. Most staff told us that their last meaningful conversation with a senior leader was not within the last year, and some staff could not recall ever having a conversation on site with someone more senior than their line manager. More senior leaders were not based at the location and so would only visit on an approximately monthly basis, although we were told that on these occasions, they did take opportunities to speak to staff. A board with the names and photos of the trust’s executive team was visible in a main corridor of the building. We were later advised that the trust's Chief Operating Officer held a listening event at the location in June 2025 and a Deputy Director of Operations was also available on-site regularly. We were also informed that senior nursing staff visit the location as part of the trust’s walkaround programme.

Some staff felt that leaders were not meaningfully invested in developing their skills or careers. We heard that some individuals in the adult outpatients service had recently participated in a trust development scheme that involved training to take on more supervisory and managerial work at a higher rate of pay, only for them to resume their previous positions at the conclusion of the scheme. This had generated the opinion amongst many in the service that leaders were training staff to take on more duties without fairly compensating them for it.

However, leaders in adults outpatients demonstrated a strong understanding of the services they managed and could explain how teams and structures worked to provide high quality care. They understood the biggest risks to the service, were experienced in managing performance and were well-qualified for their roles.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

The trust had a freedom to speak up (FTSU) policy and outpatients staff demonstrated strong compliance with mandatory FTSU e-learning modules in line with this. The trust had a named FTSU guardian and advised staff on who they could speak to about a concern, although the policy did not address FTSU champions or ambassadors in line with 2023 guidance from the National Guardian’s Office.

As such, the service had not implemented FTSU champions or equivalent roles who could raise awareness, promote a positive speaking up culture, or signpost staff with concerns. We spoke with some staff who told us of concerns that they didn’t feel able to discuss with their own manager, and despite their training did not have sufficient awareness of the FTSU policy or who they could raise these concerns to. A smaller number of staff did not feel as though their concerns would be treated anonymously in line with their wishes. However, the service reported that 3 FTSU concerns had been raised from the location in the last 12 months, indicating that at least some staff had sufficient understanding. The trust also informed us that the service had 2 Staff Engagement Associates (SEAs) who may help signpost staff to use the FTSU process if a concern was raised with them and that wider divisional teams did have FTSU champions, located at other sites.

There was evidence that leaders did not empower staff to give their views. A key concern amongst almost all staff we spoke with related to recent changes to the security arrangements of the building. While the risks associated with the change had been evaluated by leaders, various staff gave credible reasons for why they felt the change was inappropriate and that they had not been engaged at any point in the process. In the related proposal regarding these changes given at an executive team meeting, we noted that no other groups had reviewed the report prior to its submission beyond the estates and facilities team that prepared it. When we informed leaders about this concern during the inspection, they recognised that staff should have been consulted and advised they would make efforts to better engage with staff about changes such as these in future.

We scored the service as 3. The evidence showed a good standard. 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.

The trust did not have an explicit workforce equality, diversity and inclusion (EDI) policy, but the key components were covered in other documentation that included a dignity at work policy, a sexual misconduct policy, and a wellness at work process. The trust had published its EDI strategy which had been produced in collaboration with staff and other stakeholders, and produced Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) reports annually.

The trust had also developed “WWL Communities of Inclusion” which were staff networks and forums for certain groups or those with allied interests. This included groups for minority ethnicities, LGBTQIA+ people and people with a disability. Staff demonstrated an awareness of these networks and we saw visible posters in the service and in email communications.

Workforce policies and procedures in use by the service demonstrated consideration for protected characteristics and the trust had a toolkit to help facilitate this. Both leaders and staff demonstrated a good understanding of EDI and their duties related to this. Staff we spoke with did not feel discriminated against on account of their protected characteristics and some staff praised the diversity of their teams.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The adult outpatient service consisted of 1 outpatient lead who had line management responsibilities for 32 clinical staff (amounting to 26.6 whole-time equivalent), which included a sister who supported the lead in these duties. This demonstrated a large span of control for the outpatient lead. It was clear that senior adult outpatient staff depended on wider team support to ensure all responsibilities were fulfilled effectively, and staff across the service provided evidence consistent with this.

Business continuity arrangements for the adult outpatients service had not sufficiently considered the risk of longer unexpected absences of the outpatient lead and associated sister, who were the only operational leaders present each day. We were told that senior staff from other services could be used to support in the short term, and a senior leader was on call across the trust each day to help manage concerns. However certain areas, such as knowledge of the requirements of each speciality and how additional clinics could be locally arranged to meet demand, did not have fully documented processes and so in the case of unexpected absences it was not clear how this would be managed over a longer period. The loss of staff had been considered in the adult outpatients service’s business continuity plan, but this had been given the lowest possible risk rating and mitigations did not sufficiently consider the unexpected loss of service leads.

However, staff at all levels were clear about the organisational structure, their roles and accountabilities. A weekly adult outpatients team meetings took place, typically chaired by the adult outpatient lead. While there was no set agenda template, attendance was taken and minutes recorded that included essential information, which were disseminated to any staff member who could not attend. Leaders of the services also attended regular operational meetings with other outpatient departments across the trust.

The adult outpatient service had a local audit schedule, and audits were sufficient to provide assurance and oversight of the type of clinical activity taking place at the location. While staff recognised the time pressures of their work, they did not feel overburdened by audits or data collection processes. The service had an appropriate risk register which included risk ratings, mitigations, and review dates, and staff and leaders demonstrated good awareness of these risks.

We scored the service as 3. The evidence showed a good standard. 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 trust had developed a membership engagement strategy. The strategy emphasised the importance of engaging with a representative proportion of the population it served, which included people with protected characteristics and different geographical areas of the borough. The associated Council of Governors produced a biannual report on the engagement activities it had been involved in.

Locally, we saw evidence that the service engaged with other health and care providers to improve patient experiences. This included working with the local community learning disability team to ensure that patients under that service could be accommodated properly, which included arranging tours of the service for groups of patients who would be attending for appointments. The location also hosted volunteers from the community who supported both patients and staff with their needs, and who were highly valued.

We also saw that staff in the service had raised money for a local children’s charity and were well integrated with external support services who could accept referrals from them on patients’ behalf. We also saw how the service had supported a local group to obtain a blue plaque for the building to commemorate its history and legacy as a grammar school.

We scored the service as 3. The evidence showed a good standard. 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.

Service improvement work had been undertaken by outpatients staff at various levels, which in some cases had been initiated by the staff themselves. This included developing a proposal to move gynaecology services to a more appropriate setting that was sensitive to patients’ needs, and a project that was implemented to improve patient flow between audiology and Ear, Nose and Throat disciplines. The trust had also recently recognised one staff member’s contribution by giving a gold quality improvement award.

Transformation plans had been considered for outpatient services, and service leads regularly attended meetings designed to maintain and improve clinic utilisation to ensure capacity could be maximised. Aspects of the service had participated in accreditation schemes to drive improvement, where this was relevant. This included Improving Quality in Physiological Services (IQIPS) for audiology services and Baby Friendly Initiative Gold Award reaccreditations in maternity services.