Rotherham Doncaster and South Humber NHS Foundation Trust

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

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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The trust had a 5-year strategy in place which ran from 2023 to 2028. The strategy set out an ambition to provide high quality care, drive innovation and deliver the best possible outcomes for patients.

Managers described how the strategy was underpinned by 28 promises and could provide examples of how these reflected the work they were doing. For example, promise 4 aimed to provide therapeutic-based care close to home. Managers told us how the service had worked hard to reduce the number of out of area beds, wit this being implemented from a dedicated task force. There were currently only 3 out of area placement across the service.

Managers described an ongoing piece of work with staff where they were reviewing the promises, looking at how they showcased these, and how staff were living the promises in their day-to-day roles. Managers reviewed the strategy at monthly strategy meetings

Staff we spoke with were generally happy and motivated, and felt able to raise concerns, although one member of staff fed back that they felt there was a negative culture. Staff survey results for 2024 had shown a decrease in results against each of the people promise themes when compared against the 2023 scores. Following this the trust had identified key areas of focus for 2025 including trust wide actions.

Managers ensured staff completed their required training in relation to equality, diversity and inclusion. Managers ensured that they recruited people with the same vision and values who could support with the development of the service.

We spoke with patients, carers, staff and leaders within the service who were able to give examples and anecdotal evidence of how they adhered to these values and implemented them into their daily roles. Staff were committed to the service and spoke passionately about the patients they cared for.

The service followed organisational processes to recruit managers and leaders with support from human resources. This included ensuring the relevant pre- employment checks were completed.

Managers we spoke with could clearly describe their function and the roles and accountability of others within the service. Managers told us there was a high emphasis on developing staff to enable them to progress into management roles. All staff in a band 8 or above role could attend a leadership development programme. They described how this aimed to further develop leadership skills, reflect on their own skills, link in with other leaders within the trust and to focus on the 28 trust promises.

Most staff felt listened to and supported by their managers and senior managers to undertake their roles. Some staff felt senior leaders were not always responsive to their concerns.Staff said that managers within the service recognised success. Staff further added that they could suggest new ideas and could raise challenges to their seniors. Staff generally described an open-door policy.

Managers monitored staff morale through daily handovers, debriefs, team meetings and during supervision sessions. Managers encouraged staff to raise their concerns or ideas for improvement and provided feedback on decisions made in response to them.

There were regular meetings on the wards which allowed managers to hear and engage with staff who wished to raise issues; facilitate debriefs and collaboratively put plans in place for improvement.

Staff and managers felt able to raise concerns without fear of reprisals. They knew how to access the provider's whistleblowing policy and information about the freedom to speak up guardian on the intranet.

There were freedom to speak up champions within the service who staff could approach to support them in raising concerns. There was a nominated freedom to speak up guardian who worked trust wide. Managers promoted the freedom to speak up process within the service and reminded staff that they could contact the freedom to speak up guardian at any time.

Staff received training about the freedom to speak up process which aimed to ensure they felt confident and able to speak out if they needed.

The whistleblowing policy was available on the trust’s intranet. Contact details for the Care Quality Commission were displayed in ward areas as another avenue for patients and staff to raise concerns.

Staff said they felt managers were respectful of diversity. They completed occupational health reviews and made reasonable adjustments for staff where appropriate.

There was a trust wide equality and diversity lead in post. Managers told us about a REACH staff network, which was a staff- led meeting where the attendee’s reviewed equality and diversity of the workforce. This wasone of five networks which came together within the board level Trust People Council to gather staff feedback.

The equality and diversity lead published monthly bulletins on different topics related to equality and diversity. The most recent bulletin had focused equality, diversity and human rights week. Bulletins signposted staff to webinars and reading materials on various topics including celebrating cultural diversity, sexual safety and neurodiversity.

Manager described how they aimed to ensure a diverse workforce and said there had been a recent push to recruit international staff. There was an international work team who supported internal staff from the point of induction.

Staff told us respect and valuing diversity was an important part of their role, and that they respected patients' religious and spiritual needs. Staff completed diversity and inclusion training annually.

Staff told us that people were able to apply to work flexible hours to take personal circumstances into account such as caring responsibilities or health issues. Some staff within the service were already on flexible working arrangements.

We reviewed a sample of governance meeting minutes. These were attended by a range of staff and leaders. Key performance indicators and monthly audit processes were in place to help give oversight of the service. Managers had clear expectations of what care and support the service aimed to provide. Robust processes were in place to safely manage sensitive data which allowed them to maintain people’s privacy, dignity and confidentiality.

Patients were assessed and treated well. Staff adhered to legislation and knew how to deal with complaints and reported incidents and safeguarding concerns.

Managers shared lessons learned from investigating complaints, incidents and safeguarding issues.

The were risk registers in place which clearly stated each risk and mitigation in place to help reduce the risk. There was a business continuity plan which included details of who to contact and what steps to take when an emergency arose such as, adverse weather, pandemics, loss of information technology and the loss of premises

There were clear agendas for the various meetings that took place to ensure that staff and managers discussed all information relevant to the service.

Staff participated in clinical audits which provided assurance, and staff acted on the findings accordingly. We reviewed the clinical audit progress report during the inspection and saw that this identified areas for improvement and good practice, with action plans being developed where needed. Managers reviewed audit findings and action plans during regular quality meetings.

Staff understood the arrangements for working with internal and external teams and organisations, to meet the needs of the patients.

Staff submitted data and notifications to external bodies when needed. These included safeguarding referrals to the local authority and statutory notifications to the Care Quality Commission.

Managers described good working relationships with a range of external stakeholders. These included the integrated care board, police, and local authority. The service had links with a local charity who supported people on discharge from the service.

Staff invited family members and external professionals to meetings so they could discuss any issues and receive any updates about their patient's / family member's care and treatment.

The trust had processes including care programme approach meetings, discharge meetings and ward rounds to ensure all relevant partners were involved in patient’s care.

Staff had access to regular team meetings on the wards. They offered a forum for staff to propose, exchange and discuss ideas in terms of good practice.

Staff could attend reflective practice sessions facilitated by the psychology department.

Staff said managers listened and considered any ideas staff shared with them for improving the service or about concerns around patient care.

There were peer review teams within the trust who completed quality reviews at the service. These were informed by previous CQC inspections and underpinned by Royal College of Psychiatrists accreditation standards for acute inpatient services and Psychiatric Intensive Care Units. Managers said they received positive feedback from staff about these reviews which they described as a supportive measure to make improvements.

There were quality improvement leads at Swallownest Court who completed quality improvement initiatives for the service, with learning and improvements sometimes being shared across the trust. This included completing a seclusion audit which looking at seclusion documentation, patient experience during seclusion, and human rights. Following the audit, the team had identified a number of improvements to the process for documenting seclusion.

The service had recently reviewed the agenda for patient experience meetings and used patient feedback to make improvements to the meetings.

The service had recently reviewed its preceptorship nursing programme. This including reviewing the structure of the programme and making changes to improve learning days. We heard how preceptorship nurses had fed back positively about these changes.

The lead psychologist had recently completed a piece of work with a consultant psychotherapist to introduce psychotherapy treatment. This involved undertaking test cases and measuring patient outcomes. The project aimed to analyse the benefits of the treatment and check whether this would reduce readmission rates. This was a 9-session model supported by a public grant, which aimed to reduce self-harm in the community. The team had completed 24 cases so far, of which 2 patients had been repatriated and no other patients had been re-admitted.