Gloucestershire Health & Care NHS Foundation Trust

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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 inadequate. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Governance processes did not always operate effectively. Performance and risk were not always managed well. However, staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued.

At this assessment the service was in breach of legal regulation in relation to Good Governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

The service had a shared vision, strategy, and culture grounded in transparency, equity, equality, human rights, diversity and inclusion, engagement, and an understanding of the challenges and needs of people and their communities. Both the Trust and the staff team understood they were working towards meeting the conditions set at the previous assessment. We noted that the Trust was conducting its own inspections of the service and identifying areas for staff improvement.

Staff members, interviewed during focus groups and on site, reported that the culture on the wards was positive, with good staff morale.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. There were concerns about the future of the service due to the ongoing Learning Disability service review.

The service ensured effective communication with staff through emails and staff meetings, providing information in accessible formats for those whose first language was not English.

Senior staff were highly visible, with leadership present on site. They maintained an open-door policy, which staff members said they found helpful.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support. These leaders embodied the culture and values of both their workforce and organisation. They possessed the skills, knowledge, experience, and credibility needed to lead effectively, doing so with integrity, openness, and honesty.

Leaders responsible for the service had the appropriate knowledge and skills to ensure that high-quality care was provided. Ward leaders and senior managers had worked in similar services for many years and were aware of the challenges faced by frontline staff daily.

The leadership team demonstrated their capability through a wide range of knowledge and experience, with extensive backgrounds in delivering care and treatment within the mental health field.

Managers demonstrated inclusive leadership. Inclusion and diversity training was provided for staff, alongside training on learning disabilities and autism, designed to improve skills and understanding in supporting people. This training was delivered through NHS training platforms.

Staff described managers as compassionate and expressed confidence in their decisions. They welcomed the service’s zero-tolerance approach to racial abuse, which made them feel valued.

Leadership development opportunities were available, including opportunities for staff. Staff told us how they had been supported by the Trust to develop professionally.

Relatives held more mixed views about the ward management, with some feeling that communication with them was not always effective.

Quality Statement Score: We scored the service as 3. People feel they could speak up and that their voice would be heard.

A Freedom to Speak Up Guardian regularly visited the service and staff said they were aware of the process for raising concerns. The freedom to speak up guardian reported to the trust and assisted them to create an open and transparent culture of improvement and learning where raising concerns was welcomed.

Staff reported feeling happy and confident about raising concerns. They told us they would speak up if they had concerns about people’s care or treatment and believed they would be listened to, with appropriate action taken in response. For example, they cited the availability of information in accessible formats for staff whose first language was not English.

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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

There were equality and diversity networks within the service. These included cultural diversity staff networks, disabled staff network and LGBT+ staff network. Staff also had the opportunity to access staff support groups.

As part of the mandatory training, staff received equality, diversity and human rights training. Compliance was at 90% at the time of assessment. There was an equality and diversity groups in the trust who supported staff, for example, with experiences of racism from patients.

Staff were able to apply to work flexibly. For example, staff could request flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

The provider carried out equality monitoring of staff within the service to help ensure a diverse workforce.

The evidence showed significant shortfalls. The service did not have 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 governance structures were not always effective in auditing practice. As identified in this the safeguarding alerts process was not alwaysrobust.These alerts included poor documentation of risks and harm. or ensured that staff used appropriate language when describing people’s behaviour/distress in their care records. They had not always identified all possible learning from incidents or ensured premises were safe and fit for purpose and ensured the safe management of medicines.

However, the service had some structures, processes and systems of in place to support staff to deliver care and treatment. The trust had its own inspection of the service and they had started to respond to actions identified.

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 staff engaged well with external stakeholders, such as commissioners and the Local authority. Staff had the opportunity to meet with members of the provider’s senior leadership team and commissioners to provide feedback on service provision.

Relatives and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

Relatives were aware of and welcomed the service's efforts to work closely with new providers and commissioners in order to provide bespoke accommodation.

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 and research.

Staff demonstrated commitment to learning and improvement. Senior staff attended university conferences at the University of the West of England and the University of Gloucester, focusing on new innovations in learning disabilities. They worked toward Quality Network Learning Disability (QNLD) accreditation by the Royal College of Psychiatry in 2025.

Staff participated in national audits relevant to the service and learned from them

Staff successfully applied quality improvement methods and were familiar with how to implement them, including the Health and Quality Framework and LD Benchmarking.

The team introduced regular meetings aimed at developing and refining the smaller aspects of individuals' daily living experiences.