Royal Victoria Infirmary

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 one quality statement under the well-led key question. Governance systems were effective and ensured patients received a safe, well managed and effective service. Staff felt supported and were confident reporting incidents. Patient feedback was sought and acted upon.

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.

The Trust had a clear governance structure with clear responsibilities and accountability for the running of the service. There was a clinical lead who oversaw the daily running of the service as well as seeing patients. Since our previous inspection a quality and assurance lead had been appointed to strengthen governance systems. Senior leaders within the Trust had improved their knowledge and oversight of the SARC, with regular scrutiny at meetings.

There were relevant policies, procedures and risk assessments to support the management of the service which were regularly reviewed and updated as required. The performance of the SARC was scrutinised to ensure that it was meeting contractual requirements as well as responding to the needs of patients and partner agencies. While some efforts had been made to meet more regularly with the police forces served by the SARC, this hadn’t extended to the local authorities.

NHS commissioners told us they were happy that the SARC was meeting forensic timescales and performance indicators, which meant there were better chances of achieving good criminal justice and health outcomes for patients. We were told that the SARC provided data and reports when expected and they were of good quality.

There was a programme of audits carried out by clinicians within the team, overseen by the quality and assurance lead. These covers areas such as safeguarding, environmental screening and the quality of patient records. Where any shortcomings were identified this resulted in recommendations for improvement being made which were followed up.

All staff received regular supervision, appraisal and peer review to ensure their practice met professional standards and identify any training needs. Staff took pride in their work and felt supported by their managers.

Staff felt confident about reporting incidents and were aware of the Trust’s procedure, telling us they received feedback, and incidents were discussed at peer meetings, so learning was shared.

Feedback was actively sought from patients about their experience of using the service and their suggestions and comments were acted on where possible.

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.